Healthcare Bill Settlement System for EOB Translation
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Solution Overview
Problem
The healthcare industry faces high costs and inefficiencies in generating invoices and collecting payments, with healthcare service providers incurring significant costs and having low collection rates due to complex billing processes and lack of transparency for consumers, leading to frustration and delayed dispute resolution.
Innovation Solution
A healthcare bill settlement system that translates Explanation Of Benefits (EOB) data into intelligible formats for consumers, enabling them to communicate with providers before invoicing, resolve payment issues, and make electronic payments, while collecting all relevant data in a single database for better communication and dispute resolution.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If traditional healthcare billing processes are used, then providers can generate invoices and collect payments, but the costs are extremely high (15% or more of dollar amount spent) and collection rates remain low (less than 50%)
Solution Approach 1:
The system performs preliminary actions by translating EOB data into consumer-friendly formats and enabling consumers to understand and prepare for their payment obligations before the actual billing occurs. This allows consumers to make informed decisions about their payments in advance, reducing the need for costly collection efforts later.
Solution Approach 2:
The patent introduces an intermediary system that acts as a mediator between healthcare providers, insurance companies, and consumers. This intermediary translates complex EOB data into understandable formats and facilitates communication among all parties, reducing misunderstandings and improving payment collection efficiency without requiring expensive traditional billing processes.
2Loss of information
If detailed EOB data is provided to consumers, then transparency is improved, but the data is currently written in medical terms and codes that are not discernible by the average consumer
Solution Approach 1:
The system applies parameter changes by transforming the format and presentation of EOB data from complex medical terminology and codes into consumer-friendly language and formats. This transformation maintains all essential information while changing the表达方式 to be accessible to average consumers, thereby improving both transparency and understandability simultaneously.
3Reliability
If the complete claim processing chain is followed, then all parties can be compensated according to insurance terms, but the process is lengthy and involves redundant events that delay resolution
Solution Approach 1:
The system implements feedback mechanisms that allow all parties (consumers, providers, and insurance companies) to access real-time information about claim status and payment obligations. This feedback enables early identification and resolution of disputes before they progress through the entire lengthy claim processing chain, maintaining completeness while significantly reducing time delays.
Data Source
AI summary
A system and method for providing a healthcare bill settlement system whereby a given healthcare service consumer's EOB data relating to a given healthcare service item is obtained and is translated into a description of the services in language, and/or a format, that a typical healthcare service consumer can understand. The healthcare service consumer's EOB data is also used to present the healthcare service consumer with a payment calculation display and an explanation of how the healthcare service consumer's portion of the claim amount was calculated. The healthcare services consumer is then provided communication access to the healthcare services provider to propose a settlement payment prior to the healthcare services consumer receiving an invoice from the healthcare services provider. The healthcare services provider is then provided the capability to accept or reject the proposed settlement payment.