Patient Financial Liability Estimation System
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Solution Overview
Problem
Medical service providers face difficulties in accurately estimating patients' financial liability due to complex health insurance parameters and varying factors, leading to inefficient collection of payments and inadequate patient informed decision-making regarding elective procedures.
Innovation Solution
A computer-implemented method and system that accesses established payments and historical data to estimate the expected payment for a medical service, combining this with patient-specific healthcare coverage parameters to provide accurate financial information on the patient's liability, using a tiered data approach for reliable estimates.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If medical service providers attempt to collect greater portions of patient costs at the point of service, then payment collection efficiency improves, but accuracy of financial liability estimation deteriorates due to complex insurance parameters
Solution Approach 1:
The system performs preliminary estimation of patient financial liability before the actual service is rendered or at the point of service. It calculates expected payments by analyzing historical claims data, established payments, and patient-specific insurance parameters in advance, allowing providers to collect accurate payments upfront rather than attempting collection after service rendering.
Solution Approach 2:
The system introduces an intermediary computational layer that processes complex insurance parameters, historical claims data, and patient information to generate simplified payment estimates. This intermediary system bridges the gap between complex insurance adjudication rules and the need for simple, accurate point-of-service payment collection.
2Ease of operation
If providers use simplified collection methods like co-pay only, then ease of operation improves, but financial recovery deteriorates due to insufficient collection of total patient liability
Solution Approach 1:
The system replaces the manual, complex process of calculating patient liability with an automated computational system. The system automatically processes insurance parameters, historical data, and patient information to generate accurate payment estimates, eliminating the need for manual calculations while maintaining simplicity of operation at the point of service.
3Loss of energy
If providers balance bill patients after service, then financial recovery may improve, but time consumption and effectiveness deteriorate due to delayed collection and accounts receivable write-offs
Solution Approach 1:
The system calculates and determines the exact patient payment amount in advance, before the service is rendered or at the point of service. This preliminary determination eliminates the need for post-service balance billing and allows for immediate collection, preventing delays and reducing accounts receivable write-offs.
4Measurement precision
If accurate financial estimation systems are implemented, then measurement precision improves, but device complexity increases due to data access and processing requirements
Solution Approach 1:
The system is designed as a multi-functional platform that can process multiple types of data sources (established payments, historical claims data, patient-specific parameters) and serve multiple purposes (estimation, prediction, analysis). This universal system handles various data formats and insurance parameter types through a unified computational framework, managing complexity through standardization.
Data Source
AI summary
A computer implemented method involving a medical service for a patient includes estimating an expected payment associated with the medical service for the patient based on a set of data including payments for similar medical services provided to a population of individuals. The method also includes estimating a cost expected to be borne by the patient for incurring the medical service based on the estimated expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient. The method further includes presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service.