Automated Claims Processing System for Healthcare Reimbursement
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Solution Overview
Problem
The current systems for processing claims from healthcare providers to insurance companies lack efficiency due to varied submission methods, leading to delayed and rejected claims for technical reasons, such as non-compliance with insurance policies and government regulations, and errors in form submission.
Innovation Solution
A system comprising client computing devices, a structured database, and a server system that authenticates, evaluates, and submits claims by generating an interactive dashboard for healthcare providers to input patient data, comparing treatment proposals against insurance agreements, and determining coverage and reimbursement amounts.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If multiple varied submission methods are used by different healthcare providers and insurance companies, then each party can use their preferred method, but the complexity of the system increases and efficiency decreases
Solution Approach 1:
The patent implements a universal claims submission system that can handle multiple submission methods (electronic, paper, fax, portal) through a single standardized processing platform. The system accepts various input formats and automatically converts them into a standardized internal format for processing, eliminating the need for separate processing systems for each submission method while maintaining flexibility for providers to use their preferred submission channel.
2Reliability
If manual verification and evaluation processes are used for claims, then thorough review can be conducted, but processing time increases and efficiency decreases
Solution Approach 1:
The patent replaces manual mechanical review processes with automated electronic verification systems that use algorithms to validate claims against insurance policies, medical necessity criteria, and regulatory requirements. The system automatically checks for completeness, validates coding accuracy, verifies patient eligibility, and determines claim approval/rejection status without human intervention for routine claims, dramatically reducing processing time while maintaining consistent evaluation accuracy.
Solution Approach 2:
The system enables self-service functionality where the claims processing system automatically performs verification, validation, and initial adjudication without requiring manual reviewer intervention. The automated system independently evaluates claims against predefined criteria, provides real-time feedback on claim status, and only escalates complex or disputed claims to human reviewers, allowing the majority of claims to be processed autonomously and rapidly.
3Reliability
If claims are rejected for technical formalities such as form errors or missing information, then compliance with insurance policies and regulations is maintained, but claimant satisfaction decreases and rework increases
Solution Approach 1:
The patent implements preliminary validation and verification steps that occur automatically at the point of claim submission. The system checks for required fields, validates data formats, verifies medical coding accuracy, and confirms compliance with insurance policy requirements before the claim enters the adjudication process. This preliminary screening prevents rejection due to correctable errors and provides immediate feedback to providers for correcting issues before submission is finalized.
Solution Approach 2:
The system provides real-time feedback to healthcare providers during the claims submission process, immediately notifying them of errors, missing information, or compliance issues. The feedback mechanism delivers specific guidance on what corrections are needed and how to resolve them, allowing providers to correct issues on the spot rather than receiving rejection notices days later. This continuous feedback loop improves first-submission accuracy and reduces rework while maintaining regulatory compliance.
Data Source
AI summary
This document presents devices, systems, and their methods of use for authenticating, evaluating, adjusting, and/or submitting a claim to a third-party obligator. The system may include a client computing device such as a cellular phone, having a downloadable application running thereon. The application running on the client computing device may be configured for generating an interface into which a characterization of treatment to be provided from a healthcare provider to a patient having a third party obligation agreement may be entered, where the obligation agreement includes terms defining coverage for treatments to be provided that will be covered by the agreement. As such, the system may be used to generate a claims submittal packet on behalf of the health care provider for reimbursement from the third party obligator for the treatments provided to the patient by the healthcare provider.