Pharmacy Claim Adjudication System Using Contract Matching
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Solution Overview
Problem
The complex interactions between pharmaceutical product providers, PBMs, insurance plans, and governmental agencies lead to a substantial administrative burden in adjudicating and reconciling pharmacy claims, often resulting in pharmacies not receiving the full reimbursement for dispensed pharmaceuticals due to the difficulty in comparing pharmaceutical contract information with claims.
Innovation Solution
A computer-based system and method that associates pharmaceutical reimbursement contracts with claims using contract management software, comparing contract information such as reimbursement rates, BIN numbers, and co-pay rules to determine the correct payment amounts, thereby simplifying the adjudication process and ensuring compliance with contractual terms.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Ease of operation
If manual adjudication of pharmacy claims is performed, then flexibility in handling complex cases is maintained, but administrative burden and processing time increase substantially
Solution Approach 1:
The patent replaces manual mechanical adjudication processes with an automated computer-based system that electronically processes claims, matches them with contract terms, and determines reimbursement amounts without human intervention, thereby reducing processing time while maintaining accuracy
Solution Approach 2:
The system enables self-service by automatically matching claims with applicable contracts and determining reimbursement amounts autonomously, eliminating the need for manual review and allowing the system to process claims independently without human intervention
2Reliability
If comprehensive contract review is performed for each claim, then compliance with contractual terms is ensured, but processing complexity and time consumption increase
Solution Approach 1:
The system performs preliminary action by pre-storing contract terms, reimbursement rates, and eligibility criteria in a database before claims are processed. When a claim is submitted, the system retrieves applicable contract information in advance, eliminating the need for real-time comprehensive review and reducing processing complexity
Solution Approach 2:
The patent introduces an intermediary computer-based matching system that mediates between claims and contract terms. This intermediary automatically compares claim details with stored contract information, determines applicability, and calculates reimbursement amounts, simplifying the complex interaction between claims and contracts
3Measurement precision
If detailed comparison of contract information with claims is performed, then accurate reimbursement determination is achieved, but administrative burden increases
Solution Approach 1:
The system replaces manual detailed comparison processes with automated electronic matching that precisely compares claim information with contract terms, ensuring accurate reimbursement determination while eliminating the time-consuming manual review process
Solution Approach 2:
The patent uses copying by creating a digital copy of contract information and claim data that can be rapidly compared through computer processing. This allows detailed comparison of multiple contract terms with each claim without repeating the manual analysis process, thereby maintaining accuracy while improving efficiency
Data Source
AI summary
A computer-based system, method and computer program product for determining compliance with contracted pharmacy reimbursement rates. The computer-based system, method and computer program product includes storing pharmacy reimbursement contract information comprised of information regarding a plurality of contracts between a payor and a pharmaceutical product provider. A plurality of claims are received via an electronic communications network. One or more of the plurality of received claims are compared to at least one of the plurality of contracts by identifying, via computer processor, one or more of the plurality of contracts having pharmaceutical reimbursement contract information that is common with one or more of the received claims. If only one contract is identified, the one contract is associated with the received claims. An indication of the association of the one identified contract with one or more of the received claims is stored in a computer memory.