Primary Server Shadow Data for Real-Time POS Insurance Adjudication
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Solution Overview
Problem
Current systems for managing insurance claims and benefits processing are inefficient, requiring real-time interaction with insurance servers and lacking in immediate payment capabilities for service providers, leading to delayed reimbursements and complex benefit tracking.
Innovation Solution
A primary server system that duplicates select insurance data in a shadow data store, allowing for near real-time processing of insurance claims and benefits redemption without constant interaction with the insurance server, enabling quick reimbursement requests and immediate payment processing through benefit buckets and pre-authorization/clinical review management.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If real-time interaction with insurance servers is required for claims processing, then data accuracy and reliability are improved, but processing speed and operational efficiency deteriorate
Solution Approach 1:
The system performs preliminary actions by duplicating insurance data to a shadow data store before claims processing occurs. This pre-positioning of data enables fast local processing without requiring real-time server interaction during the actual claims adjudication, thus resolving the contradiction between reliability and processing speed
Solution Approach 2:
The system creates a copy of the insurance data in a shadow data store that mirrors the structure and content of the primary insurance server database. This copying mechanism allows the POS system to process claims locally with high speed while maintaining data accuracy through periodic synchronization with the insurance server
2Measurement precision
If multiple insurance programs and benefits are tracked in real-time, then benefit tracking accuracy is improved, but system complexity and processing overhead increase
Solution Approach 1:
The system segments the complex insurance data structure into distinct components including benefit buckets, program identifiers, and service code mappings. This segmentation is implemented in the shadow data store, allowing each component to be processed independently while maintaining overall benefit tracking accuracy and reducing processing complexity
Solution Approach 2:
The shadow data store is designed as a universal structure that can handle multiple insurance programs, benefit types, and service categories simultaneously. This multi-functional design consolidates what would otherwise require separate processing systems, thereby maintaining tracking precision across diverse benefits while managing system complexity
3Loss of time
If immediate payment processing is enabled at POS, then service provider cash flow is improved, but transaction processing complexity increases
Solution Approach 1:
The system performs preliminary actions by pre-calculating benefit amounts and determining payment eligibility before the actual transaction occurs. The shadow data store contains pre-configured benefit buckets and program rules that enable immediate payment determination without complex real-time calculations, thus enabling fast reimbursement while managing processing complexity
Solution Approach 2:
The primary server acts as an intermediary between the POS system and the insurance server. It receives transaction requests, processes them using the shadow data store for immediate payment determination, and only contacts the insurance server when necessary for verification or exceptions. This intermediary approach enables fast payments while reducing overall system complexity
Data Source
AI summary
A system and method are presented that utilizes a primary server having shadow data and benefit bucket data to provide adjudication and payment processing of insurance payment requests without requiring interaction with an insurance server and normal adjudication processes. The primary server can handle adjudication and payment processing for a plurality of insurance providers. An alternate payment method can be identified with a member identifier, allowing both insurance payment adjudication and member payment through the alternate payment method. The primary server can provide benefit processing for retail discounts, and store value benefits for authenticated purchase transactions. A variety of discounts, stored value benefits, insurance benefits, and alternate payment mechanisms can be incorporated into a single transaction and handled in real-time during the transaction.