Patient Financial Responsibility Calculation for Multi-Prescription Groups
Find Innovative SolutionsGenerate Solutions
Solution Overview
Problem
The complexity of healthcare plans, including varying co-pays, deductibles, and coverage rules, makes it difficult for pharmacists and prescribers to accurately determine a patient's financial responsibility for multiple prescription products in real-time, hindering the provision of timely cost information and adherence to prescribed medications.
Innovation Solution
A system and method that facilitate real-time determination of patient financial responsibility by electronically transmitting healthcare transactions to a service provider computer, which adjudicates multiple prescription products, calculates total patient pay amounts, and automatically generates reversal transactions, ensuring accurate and efficient cost assessment.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If healthcare plans include varying co-pays, deductibles, and coverage rules for different prescription products, then the insurance coverage becomes more comprehensive and adaptable to different medication types, but the complexity of determining patient financial responsibility increases significantly
Solution Approach 1:
The patent segments the financial responsibility determination into distinct components: identifying individual prescription products, determining applicable coverage rules for each product, calculating co-pays and deductibles separately, and then aggregating these components to determine total patient responsibility. This segmentation allows the system to handle complex multi-product scenarios by breaking them down into manageable individual product assessments.
Solution Approach 2:
The system performs preliminary identification and classification of prescription products before final cost calculation. By pre-identifying which coverage rules apply to each product type and pre-calculating individual product costs, the system prepares the necessary data structures and cost components in advance, enabling faster and more accurate final aggregation of total patient responsibility.
2Measurement precision
If pharmacists and prescribers manually calculate patient financial responsibility for multiple prescription products, then they can understand each product's coverage details, but the time required to provide accurate cost information increases significantly
Solution Approach 1:
The patent introduces an intermediary computerized system that acts as a mediator between the prescription products and the patient. This intermediary automatically identifies each prescription product, applies the appropriate coverage rules, calculates individual and aggregate costs, and provides the final financial responsibility determination. This intermediary eliminates the need for manual calculation while maintaining accuracy through systematic automated processing of all cost components.
Solution Approach 2:
The system replaces the manual mechanical calculation process with automated computer-based processing. Instead of manually identifying products, selecting coverage rules, and calculating costs, the patent uses automated algorithms to perform these functions, substituting human cognitive and computational efforts with machine-based systematic processing that is both faster and equally accurate.
3Measurement precision
If the system processes multiple disparate prescription products through separate adjudication processes, then each product receives individualized coverage assessment, but the overall processing efficiency and productivity decrease
Solution Approach 1:
The patent merges the individual product assessment processes into a unified systematic approach. While each prescription product is individually identified and assessed for its specific coverage rules and costs, the system combines these individual assessments into a single integrated processing flow that aggregates costs and determines total patient responsibility in one coordinated operation, rather than requiring separate complete processing cycles for each product.
Data Source
AI summary
Systems and methods are provided for determining patient financial responsibility for multiple prescription products across multiple healthcare transactions. A service provider computer can receive multiple healthcare transactions, and can evaluate each to determine if it includes a total group transaction number and a transaction number. The service provider computer can compare the transaction number to the total group transaction number to determine if all transactions within a group have been received. Once received, the transactions can be transmitted to the claims processor computer for adjudication. Upon receiving the adjudicated response for each transaction within the group, the service provider computer can identify the patient co-pay for each of the adjudicated responses in the group and can calculate a total patient pay amount based on the group of patient co-pays. The total patient pay amount may then be transmitted to a healthcare provider computer associated with a healthcare provider.