Standardized Genetic Test Identifier Mapping System
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Solution Overview
Problem
The lack of consistent identifiers for genetic testing products across the industry leads to inefficiencies, including slow reimbursement, administrative burdens, long wait times, and increased healthcare costs, due to inconsistencies in test ordering and billing processes.
Innovation Solution
A system utilizing machine learning to create a unified representation of claims by de-identifying payment claims, matching them to specific genetic testing units (GTUs) and bins, which are consistent identifiers for tracking attributes over time, thereby standardizing molecular and diagnostic testing products and services.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If laboratories provide different information about their specific tests without consistent identifiers, then each laboratory can maintain flexibility in test description and formatting, but it results in administrative burdens, slow reimbursement, and inefficiencies for hospitals, clinicians, and payers
Solution Approach 1:
The patent introduces an intermediary mapping system that translates between laboratory-specific test identifiers and standardized industry identifiers (CPT codes, ICD-10 codes, etc.). This intermediary layer allows laboratories to maintain their flexible, proprietary test descriptions while enabling hospitals, clinicians, and payers to use standardized codes for efficient ordering, billing, and reimbursement processing.
Solution Approach 2:
The system transforms test identification from unstandardized, laboratory-specific parameters to standardized industry-wide parameters. By changing the identifier parameters to include CPT codes, ICD-10 codes, and other standardized codes, the system enables consistent tracking and processing across the entire healthcare ecosystem while preserving the original laboratory test descriptions.
2Productivity
If laboratories use proprietary test identifiers without industry standardization, then each laboratory can independently track and manage their test products, but it leads to lack of transparency and difficulty in determining medical necessity for reimbursement
Solution Approach 1:
The patent segments test identification into multiple hierarchical layers: laboratory-specific identifiers for internal management, standardized CPT codes for billing and reimbursement, ICD-10 codes for diagnosis tracking, and other standardized identifiers. This segmentation allows each layer to serve its specific function while maintaining transparency and traceability across the entire system.
Solution Approach 2:
The standardized identifier system serves multiple functions simultaneously: it enables laboratories to track their test products, allows hospitals to order tests efficiently, facilitates clinician decision-making, supports payer reimbursement processes, and provides transparency for determining medical necessity. This multi-functional identifier system resolves the contradiction between laboratory productivity and information transparency.
3Ease of manufacture
If there are no consistent identifiers for tracking testing products, then laboratories can independently manage their product information, but it results in long wait times and wasted co-pays for patients due to mis-ordered tests
Solution Approach 1:
The system implements feedback loops where standardized identifiers enable real-time verification of test ordering accuracy. When tests are ordered with standardized CPT and ICD-10 codes, the system can immediately verify medical necessity, match appropriate reimbursement rates, and prevent mis-ordering errors. This feedback mechanism eliminates patient wait times and wasted co-pays by ensuring correct test selection from the outset.
Data Source
AI summary
The present disclosure relates to systems and methods for tracking, monitoring, and standardizing molecular and diagnostic testing products and services. A claim for payment, corresponding to a testing product or service, may be received, and a de-identification may be performed on the claim to remove personal identifiers from the claim to create a de-identified claim file. From the de-identified claim file, a unified representation of the claim may be created to form a structured payment claim object. The claim object may be matched to a specific testing product and/or a bin.