Electronic Coordination of Benefits Claims Processing
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Solution Overview
Problem
Healthcare providers face costly and inefficient paper-based processes when submitting coordination of benefits (COB) claims to multiple payers, as many providers lack electronic data or compatible medical billing software, limiting the ability to process COB claims electronically.
Innovation Solution
A healthcare system and method that enables providers to electronically process COB claims by receiving patient information, communicating payment requests, identifying COB opportunities, and pre-filling claims with available data, such as HIPAA 837 or 835 data, to facilitate submission to multiple payers, including primary and secondary payers, even without existing electronic data or compatible software.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If providers use paper-based processes to submit COB claims, then claims can be submitted to multiple payers, but processing costs are high and efficiency is low
Solution Approach 1:
The patent replaces the mechanical paper-based mailing system with an electronic data transmission system. Providers submit COB claims electronically through a web interface, and payers receive and process these claims digitally, eliminating the need for physical paper handling, mailing, and manual data entry across the entire COB workflow
Solution Approach 2:
The system creates and transmits electronic copies of claim data between providers and multiple payers. The electronic claim representation can be replicated and sent to primary and secondary payers simultaneously without additional physical resources, reducing marginal costs to near zero while maintaining full claim information integrity
2Adaptability or versatility
If providers lack electronic data or compatible software, then they cannot electronically process COB claims, but they still need to submit claims to multiple payers
Solution Approach 1:
The patent implements a universal web-based interface that can accept COB claim submissions from providers regardless of their existing software capabilities. The system handles multiple data formats and submission methods, allowing providers with or without electronic data systems to participate in electronic COB processing through a common platform
Solution Approach 2:
The patent introduces an intermediary clearinghouse system that mediates between providers and payers. This intermediary accepts claims from providers with limited electronic capabilities, performs necessary data transformations and COB logic processing, and submits appropriately formatted claims to multiple payers, bridging the gap between disparate systems
3Reliability
If paper EOB is mailed to COB payer, then adjudication can be facilitated, but the process is costly and time-consuming
Solution Approach 1:
The patent replaces the mechanical paper EOB mailing system with electronic data exchange. The clearinghouse electronically transmits adjudication results and coordination information to secondary payers through digital channels, eliminating mailing delays and enabling near-real-time processing while maintaining complete adjudication accuracy through structured electronic data formats
Data Source
AI summary
A healthcare system coordinating benefits includes a provider computer configured to receive patient information for a patient and to communicate a payment request to a payer computer. The provider computer includes programmed instructions to identify a coordination of benefits claim, obtain certain data from a response received from the payer computer in response to requests from the provider computer, store the certain data from the response, and provide the stored certain data in a coordination benefits claim.