Payment System Suspend Clearing for Uncertain Transaction Amounts
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Solution Overview
Problem
Healthcare providers face difficulties in collecting payments due to the uncertainty of transaction amounts, as co-insurance plans result in percentage-based payments that are only determined after the claim is processed, leading to delayed finalization of transaction amounts and complications in the transaction process.
Innovation Solution
A payment system that facilitates 'long running transactions' with suspended clearing and delayed settlement, allowing for real-time estimation of consumer responsibility and recognition of a suspend clearing flag to manage transactions until the final amount is determined, thereby enabling secure payment assurance for healthcare providers at the point of service.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If co-insurance based plans are used to determine patient responsibility after claim processing, then payment accuracy is improved, but transaction time is significantly increased (up to 90 days)
Solution Approach 1:
The system performs preliminary action by securing an estimated amount from the patient at the point of service before the claim is fully processed. The payment system holds this estimated amount and suspends clearing until the final amount is determined through claim adjudication, thereby resolving the contradiction between needing accurate final payment amounts and requiring timely collection.
Solution Approach 2:
The system dynamically adjusts the transaction state based on claim processing status. The clearing process is suspended during the adjudication period and automatically resumed when the final amount is determined. This dynamic state change allows the system to maintain both timing flexibility and payment accuracy throughout the variable-length processing cycle.
2Reliability
If funds are held for the entire adjudication period to ensure accurate payment, then payment reliability is improved, but operational complexity is increased
Solution Approach 1:
The payment system acts as an intermediary between the provider and the patient's payment account. It receives the estimated amount from the provider, holds it securely, and releases the final amount after claim adjudication. This intermediary function simplifies the overall process by centralizing the holding and release mechanism, reducing operational complexity while maintaining payment reliability.
Solution Approach 2:
The system incorporates feedback mechanisms where the payment system monitors claim processing status and automatically responds by suspending or resuming clearing based on the final amount determination. This automated feedback loop eliminates manual intervention and reduces operational complexity while ensuring reliable payment processing.
3Ease of operation
If traditional co-pay based plans are used, then collection process is simplified, but payment accuracy deteriorates due to fixed amounts not reflecting actual patient responsibility
Solution Approach 1:
The system performs preliminary collection of an estimated amount from the patient at the point of service, which simplifies the collection process for the provider. This estimated amount is then adjusted based on the actual claim adjudication results, maintaining payment accuracy while preserving collection simplicity through the hold and release mechanism.
Data Source
AI summary
A first acquirers receives, via a payment network configured to facilitate transactions between multiple issuers and multiple acquirers, an authorization response flagged with a flag. The flag indicates that clearing of a first transaction, associated with the authorization response, is to be suspended. The first transaction initially has an uncertain amount, and is associated with a first payment account, of a first user, associated with a first issuer. Subsequent determination of a final certain amount for the first transaction is awaited. Upon determination of the final certain amount, the first one of the acquirers proceeds with clearing the first transaction, based on the final certain amount. The steps are repeated for at least a second acquirer and at least a second transaction. The second transaction is associated with a second payment account, of a second user, associated with a second one of the issuers. The steps are carried out by an operator of the payment network, and the flag is understandable to the first and second issuers and the first and second acquirers.