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Description  |
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BACKGROUND OF THE INVENTION
The present invention relates to the computerized financial transactions
art. It finds particular application in conjunction with reimbursements
made for physician's services and the processing of medical insurance
claims.
Heretofore, it has been necessary for physicians to process a wide variety
of papers and forms to receive compensation for their services. The
numerous insurance companies which have provided medical insurance to the
consuming public have had a wide range of different forms which must be
submitted to receive compensation. Some of the forms were to be submitted
by the doctors and others were to be submitted by the patients. Under some
insurance policies, the patient has been a co-insurer who was responsible
for a portion of the medical bills. In other instances, the physican's
fees have exceeded the compensation paid by the insurance company, leaving
a balance to be paid by the patient. Some insurance companies have paid
the benefits directly to the patient and the patient has reimbursed the
doctor; whereas, other insurers have paid the doctor directly. Even as to
monies paid by the patient, some patients paid by check or cash at the
time the services were rendered, some paid by credit card, and others were
invoiced. The processing of the numerous different types of insurance
forms and modes of payment has created a major paper processing problem.
Many physicians and clinics have had to hire extra staff whose sole job
function was to handle this paperwork. The extra staff increased over head
which was passed on to the consumer in the form of higher medical bills.
Even once the forms were filled out and submitted, the physician still
faced the problem of collecting the amounts invoiced to the insurance
companies and patients. Forms which were filled out improperly were
commonly returned to the physican to be processed again. Even forms that
were properly filled out commonly required extended durations for
processing by the insurance companies before reimbursement checks were
mailed. In some instances, the processing time was several months. If the
claim exceeded the limits of the insured policies, the same processing
time elapsed before the physician was advised that he was receiving only
partial payment. Partial payments by the insurance companies necessitated
invoicing the patients, possibly months after the services were provided.
These delays between the time the services were provided and when
compensation was received again increased the physician's overhead. This
increase in overhead again resulted in higher medical costs to the
consumer.
The present invention provides a new and improved computerized financial
transaction system for physicans and other medical personnel which
overcomes the above referenced problems and others.
SUMMARY OF THE INVENTION
In accordance with one aspect of the present invention, a financial
transaction system is provided for physicians' offices. A plurality of
physician terminals, which are located in physicians' offices, are
interconnected with a central processing system. Each physician terminal
includes means for entering at least a patient identification, a medical
service identification, a physician identification, and an insurance
carrier identification. Each terminal further includes a modem means for
electronically conveying the entered identifications to a modem means of
the central processing system. The central processing system includes a
patient file means for verifying the patient identification and a
physician file means for verifying the physician identification. A claims
means transforms the received identifications into a preselected format
for the identified insurance company.
In accordance with a more limited aspect of the invention, each physician
terminal includes a key board array for entering identifications, a swipe
card reader for reading identifications electronically from a card, and a
display terminal.
In accordance with another more limited aspect of the present invention,
the central processing system includes a statement means for providing
periodic statements of charges and payments for one or more of the
physicians, the patients, and the insurance companies.
In accordance with another more limited aspect of the present invention,
the central processing means includes a funds transferring means for
transferring funds collected from the insurance carrier directly to a bank
account of the appropriate physician.
In accordance with yet another more limited aspect of the present
invention, a data link is provided between the central processing system
and computers of one or more of the insurance companies for electronically
conveying claims from the claim means directly into the insurance
companies' computers.
A primary advantage of the present invention is that it expedites the
processing of medical claims and bills.
Another advantage of the present invention is that it reduces the cost of
claims processing and speeds the collection of fees by physicians.
Another advantage of the present invention is that it reduces the cost of
claims processing by insurance companies.
Yet another advantage of the present invention is that it standardizes the
insurance claims and medical payment procedure for patients and reduces
medical costs through reduced overhead.
Still further advantages of the present invention will become apparent to
those of ordinary skill in the art upon reading and understanding the
following detailed description.
BRIEF DESCRIPTION OF THE DRAWINGS
The present invention may take form in various components and arrangements
of components and in various steps and arrangements of steps. The drawings
are only for purposes of illustrating a preferred embodiment and are not
to be construed as limiting the invention.
FIG. 1 is an overview of a financial transaction system in accordance with
the present invention;
FIG. 2 illustrates a physician's office terminal;
FIG. 3 is an overview of a process flow for the physician's office
terminal;
FIG. 4 is a more detailed process flow for the office terminal;
FIG. 5 is a diagrammatic overview of the central processing system;
FIG. 6 is an overview process flow for data handling after entry;
FIG. 7 is a detailed illustration of the data processing at the physician
terminal for a sign-up process;
FIG. 8 is a detailed illustration of the verification data flow process at
the physician terminal;
FIG. 9 is a detailed illustration of a claim entry processing at the
physician terminal;
FIG. 10 is a detailed illustration of the data processing at the
physician's terminal during a credit card transaction;
FIG. 11 is a detailed illustration of the transaction data processing
procedure at the physician's terminal;
FIG. 12 is a detailed illustration of the library access data processing
procedure at the physician's terminal;
FIG. 13 is a detailed illustration of the sign-up transaction process in
the central processing system;
FIG. 14 is a detailed illustration of the enrollment verification process
at the central processing system;
FIG. 15 is a detailed illustration of the transaction change process at the
central processing system;
FIG. 16 is a detailed illustration of the claim entry data processing at
the central processing system;
FIG. 17 is a detailed illustration of the line item entry process at the
central processing system; and,
FIG. 18 is a detailed illustration of the credit card charge process at the
central processing system.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
With reference to FIG. 1, the medical payment system includes a plurality
of remote terminals A that are interconnected with a central processing
system B. Each remote terminal is disposed in a physician's office or
other medical facility and is interconnected with the central processing
system by existing telephone lines or other data links. The central
processing system is interconnected with other electronic and computerized
equipment C, commonly at remote locations. In particular, the central
processing system may be interconnected directly with insurance companies,
banks and financial institutions, electronic mail facilities, and the like
to communicate information electronically therebetween. Data which cannot
be communicated electronically is conveyed to a printer D to print a hard
copy.
At each remote terminal, data are entered regarding charges and payments
for medical services. The information which is forwarded from the remote
terminals to the central processing system includes identifications of the
physician, the patient, the medical service, and the patient's insurance
carrier. Additional information may also be transmitted, such as a credit
card identification for credit card payments, check and bank information
for check payments, cash payments, no charge services, or the like. The
central processing system verifies the physician, patient, and insurance
company identifications. The services, physician, and patient
identifications are reformated into the appropriate format for claims of
the identified insurance carrier. Preferably, the claims data are
electronically communicated directly to the computers of the insurance
companies. Where appropriate, printed claims are prepared on the printer D
and forwarded to the insurance carrier.
The insurance carrier returns financial credit information, preferably by
an electronic funds transfer. When funds are received from the insurance
company, whether by check or electronic funds transfer, the central
processing system B communicates directly or by printed authorization with
the computers of banks and other financial institutions to transfer the
appropriate funds to the account of each physician. For patients whose
insurance contract only provides less than full compensation for the
services provided, the central processing system B determines the balance
due from the patient and notifies the remote terminal. The balance may be
paid by credit card through the central processing system, cash, or by a
billing generated by the central processing system. The funds are again
transferred through or at least recorded by the central processing system
such that statements can be provided on a monthly or other regular basis
to the physician and, where appropriate, to the patient.
With reference to FIG. 2, each remote terminal includes a manual data entry
keyboard 10 for entering medical service and other data. A card reader 12
reads patient identification cards, physician identification cards, credit
cards, and the like. Preferably, the card reader includes a swipe reader
that reads magnetic tape affixed to the cards. However, the reader may be
configured to access the processor of smart cards, to read bar codes, to
read infrared codes, or the like as may be appropriate to the format.
Commonly, the patient identification and the insurance company
identification are read from the patient's identification card and the
physician's identification is read from a physician identification card
and stored in the terminal. However, on initially signing up or when
changing patient records, patient information is entered on the keyboard.
A display or area means 14 presents entered data, messages concerning
entered data, and responses from the central processing system. A voice
communication means or telephone receiver 16 enables an operator to
communicate by voice with operators at the central processing station and
otherwise functions as a conventional telephone receiver.
With reference to FIG. 3, each remote terminal has a computer 20 which is
preprogrammed to carry out preselected routines. The computer includes a
transaction memory or library file 22 for storing each entered medical
claim to provide an on-site record. A physician library file 24 stores
physician information for each physician in the practice, who is
frequently consulted, or whose services are othewise billed through the
remote terminal. A procedures library or memory means 26 stores the
medical services or procedures most routinely performed by the physicians.
When entering a claim, the common details of these procedures are
retrieved from memory rather than being reentered every time. A set-up
library file or memory means 28 enables additional storage files to be
set-up as may be required by the physician, e.g. a daily report generator.
A printer 30 may be provided for printing patient receipts, daily
physician statements or reports, insurance company claims for submission
by a patient for reimbursement, or the like. A modem 32 communicates with
the central processing system B over telephone or other data
communications lines.
With reference to FIG. 4, the display means 14 displays an indication 40
that the computer 20 is ready for use in a ready state. The computer
receives the patient's identification number by accessing the swipe card
reader at 42 or by monitoring the keyboard at 44. Additional
identifications 46 are keyed in as a cross check on the authenticity of
the patient card. Such cross check information may include the patient's
zip code, family history, social security number, or the like. A display
control 48 displays selectable routines that may be chosen including a
sign-up process 50, a claims process 56, a verification process 52, a
change process 54, which are described in greater detail in conjunction
with FIGS. 7-10, respectively, below.
The remote terminal also permits the operator to select specialized
functions. For example, at 60 the operator can command the terminal to
bring up a speed claim procedure 62. In the speed claim procedure, a
library or memory within the remote terminal, which has a plurality of
prestored medical service information therein, is accessed. Commonly, as
described below, the physician has entered the information for the two or
three dozen most commonly performed procedures in his office. In the speed
claim transaction process, the information regarding these most common
procedures can be accessed from the procedures library file 26 at the
touch of a button and transmitted to the central processing system as part
of a claim. This saves re-entering the medical service information in
full. At 64 the keyboard also enables the operator to actuate the voice
communication means 16 to dial up a question center at 66 to answer data
entry questions.
The operator may also key at 70 a command to bring up a prerecorded credit
card transaction procedure 72 described in greater detail in conjunction
with FIG. 11. The credit card transaction procedure brings up on the
display screen 14 a series of questions and instructions to walk the
operator through a credit card transaction. The credit card transaction
process further formats the requested credit card information
appropriately for transmission to the central processing system. A
transaction library key 74 enables the operator to initiate a transaction
library process 56. The transaction library enables the operator to review
each medical service payment transaction entered through the remote
terminal. The operator may also correct or edit transaction data. Reports
and compilations of the stored data are also retrievable.
A library access key 80 enables the operator to enter a general library
process 82. The general library process may address a physician library
retrieval routine to retrieve background information on physicians from
the physician library 24. A set-up process routine 86 allows new and
additional libraries to be set up. A procedure process or subroutine 88
enables the physician to prerecord medical service claim information such
as fees, place, patient body site, and the like for each of a plurality of
regularly performed covered physicians' treatments. This enables the speed
claims of process 62 to be customized to the physician's practice. The
fees may be set in accordance with groups, insurance companies, or the
like. When the patient identification, insurance company, and medical
treatment are entered as part of a claim, the appropriate supporting
information about the treatment including the fee are retrieved from the
procedure library 26 and need not be reentered for each claim.
An electronic mail key 90 enables an electronic mail procedure 92 to be
entered. The electronic mail procedure provides for the same or next day
delivery of insurance claims, patient statements, and the like.
With reference to FIG. 5, the interaction of the central processing system
B with the remote terminal is described in greater detail. First, each
terminal logs on at 100 and a confirmation of a valid data stream is made
at 102. An indication of the action to be taken is selected at 104.
If the sign-up procedure 50 is selected, an enrollment routine 110 is
initiated. Entered insurance company information and credit card
information is cross checked with data on store at the central processing
system at 112. The entered insurance company and zip code are validated at
114. Selected portions of the data are identified at 116 and used to build
cross reference indices. At 118, the new patient data including the
patient identification, insurance company, and zip code are entered into
the appropriate data bases. An acknowledgement is constructed at 120 and
returned to the remote terminal for display.
If the verification process 52 has been selected, an enrollment
verification routine 122 is initiated. The insurance carrier and
correspondence between the entered and prerecorded patient's zip code is
validated at 124 to assure that the change is authorized. Records of the
patient's name, address, and patient history are retrieved at 126 from
memory and revised. An acknowledgement reply is constructed at 128 for
return to the remote terminal for display to the operator.
If the enrollment change process 54 has been selected, a change enrollment
data procedure 130 is initiated. The insurance company identification and
zip code are validated at 132. The insured's record is located within the
insured or patient file at 134 and the appropriate changes and deletions
to the patient information are made at 136. The revised records are
reapplied at 138 to the appropriate data bases. An appropriate
acknowledgement is constructed at 140 for return and display on the remote
terminal.
If the claim process 56 has been selected, a claim header, i.e. basic claim
information including patient, physician, medical service fee, insurance
company and other identifications, are filed at 150. Information about the
patient or insured is validated at 152. For example, the patient
identification, zip code, or the like may be compared with data stored in
a patient or insured file at the central processor to assure that the
transaction is charged to the proper insured. Next, at 154 the physician
identification is validated. Again, the received physician identification
may be compared with data in a prerecorded physician's file. For
compactness of data transmission, the claim information may be transmitted
in a relatively compact form which is then expanded at 156. An appropriate
claim record is formated at 158 and stored for dialog transmission to the
appropriate insurance carrier. At 160 an acknowledgement reply is
generated to the remote terminal to provide an indication on the display
means 14 that the transaction is complete or, if appropriate, that there
was an error in the received data.
If the physician charges are to be amended, a line item charge file process
is initiated at 162. The claim header is validated at 164 and the
diagnosis or procedure described in the claim header is exploded at 166 by
retrieving information on the identified procedure from memory. A claim
processing flag is generated at 168. The diagnosis, procedure, and fees
are entered at 170 into the patient, insurance, and other appropriate data
bases. An appropriate acknowledgement is constructed at 172 and returned
to the remote terminal for display.
If a previously filed claim is to be deleted, a claim purge process 174 is
initiated. The physician identification data is validated at 176 to be
sure the treating or other authorized physician is changing the claim. The
program determines at 178 whether the claim in question was previously
filed and stored in the central processing computer memory. The claim in
question is deleted from the file at 180. A reply is constructed at 182
acknowledging the purge and returned to the remote terminal for display on
the display means 14. The acknowledgement indicates either that the claim
has been deleted or that there is an error in the instructions and that it
has been completed.
If a credit card transaction was selected at 72, then a credit card charge
routine 190 is entered. The credit card number is validated at 192 by
comparison against an invalid credit card list. The physician
identification is validated at 194. The appropriate charges are applied to
the credit card data base and credited to the physician's account at 196.
An acknowledgement is constructed at 198 and returned to the remote
terminal.
If an electronic mail procedure was selected at 92, an electronic mail
processing routine 200 is entered. The electronic address is validated
202. At 204, all electronic mail going to the same address is gathered so
that all mail is sent at regular intervals. An acknowledgement is
constructed at 206 and returned to the remote terminal.
With reference to FIG. 6, various financial transactions and reports are
generated by the central processing system as a result of the entered
claim and other information.
The central processing system separates patient statement data at 220 and
generates patient statements 222. Updates from generating the patient
statement are monitored at 224 and entered at 226 in the patient,
physician, insurance company, and other appropriate data bases. Patient
payments or failure to pay are recorded in an accounting file 228.
When funds have been received from the insurance company at 230, any
compensated prompt payment claims are closed. The electronics transfer
routine is requested at 232. An electronic funds transfer generation
program 234 generates a printed report 236 and an electronic funds
transfer tape 238 for transmission to a bank or other financial
institution which credits the funds to the physician's account.
Electronics funds transfer data is recorded at 240. An up-date program 242
updates the data stored in a physician payment file 244 to reflect the
electronic funds transfer payment data.
A credit card program 250 enables a credit card generator program 252 to
create a credit card tape 254 for transmission to the appropriate credit
card company and enables a printed report 256 to be made up for
bookkeeping purposes. A credit card up-date program 258 monitors the
information from the credit card transaction. An up-date program 260
causes the up-date from the credit card transactions to be stored in the
accounting data base 228.
Claims are designated by the physician to be early or prompt payment claims
or segregated into a prompt payment fund 270. After a preselected number
of days, e.g. fourteen, the amounts covered by insurance on the prompt
payment claims are organized by physician and a report generating step 272
to create a funds transfer request 274. The electronic funds transfer
request may be an electronic funds transfer or may be a funds transfer
authorization transferred to a selected financial institution. For a
prompt payment patient claim for which payment has been refused or reduced
by the insurance company, a patient billing routine 276 generates patient
bills 278 for the difference or deficit.
In this manner, claims information is received at a central processing
system from a plurality of remote terminals. The central processing system
sorts the claims by insurance company and reformats the claims into the
appropriate format for each insurance company. Where appropriate, patient
bills and credit card fund transfers are also made. As funds are returned
from credit card companies, insurance companies, or patients, the funds
are credited to the physicians' accounts. The financial record of claims
made, claims outstanding, funds received, any loans against accounts
receivable, and the like are collected and printed as a physician's
financial statement. The funds that have been credited to the physicians'
accounts are transferred electronically or by paper to the physician's
account at an appropriate financial institution.
The details of the data handling of the remote terminals A are set forth in
FIGS. 7-12.
With reference to FIG. 7, the sign-up procedure program 50 first requests
at 300 whether the patient's social security number or other portion of
the patient identification was entered. If not, the social security is
entered at 302. If the patient social security was previously entered, a
patient identification number is entered at 304.
Demographic information on the insured patient is entered at 306 such as
first, middle, and last names, sex, patient number, and the like. At 308,
similar information is entered for the insured's spouse, where
appropriate. The insured and the insured spouse address and other joint
information are entered at 310. Insurance information is entered at 312
such as the primary carrier, the group, the plan, and the like. Any
secondary insurance is entered at 314. To the extent charges are not
covered by insurance, an election is entered at 316 to pay by cash or by
credit card. If credit card payment is elected, the appropriate credit
card information is read from the card's magnetic strip and stored at 318.
A display indicating that the sign up is complete is displayed at 320.
At 322, an inquiry is made whether or not a claim is to be filed in
conjunction with the sign-up. If a claim is to be filed, the system goes
to the claim processing means 56. If no claim is to be filed, a dial up
means 324 communicates the sign up information to the host computer at the
central processing system B. The host computer determines whether there
are any errors in the transmitted data and returns an error or no error
indication at 326. If there are errors, the operator may elect at 328
either to review the entered data by returning to step 46 or terminate the
sign up procedure. If no errors are present, an acknowledgement is
displayed at 330. At 332, the operator verifies that the transaction is
proper. If the operator indicates an error in the transaction, then a
means 334 allows the operator either to leave the transaction as is, or to
have a means 336 delete the sign up data from the host computer. Upon
completing the deletion, an acknowledgement 338 is returned to the
operator.
With reference to FIG. 8, if the verification process 52 is selected, a
dial up means 350 dials up the host computer of the central processing
system B and transfers the entered insured patient information. The host
computer verifies the information and returns an indication at 352 whether
or not there were any errors or discrepancies. If no errors or
discrepancies were determined by the host computer, the lack of errors is
acknowledged on display means 354. At 356, the operator is given the
opportunity to file a medical services claim. If claims are to be filed,
the program goes to the claim process 56. If the central computer
determines that there are errors, the operator is given the opportunity at
358 to elect whether or not to review the patient information that was
sent for verification or return to the ready state 40.
The change process 54 of FIG. 4 is substantially the same as the sign-up
process discussed above in conjunction with FIG. 7. The data is called up
and reviewed in the same order that it is entered. If any entered data is
to be altered or deleted, a prefix indicating an alteration is typed ahead
of the substitute data. If a field of entered data is to be erased, an
erase prefix or symbol is entered for that field. If neither an alteration
nor an erase prefix or symbol is entered, the data remains unchanged.
With reference to FIG. 9, when a claim is to be filed, the terminal
software checks at 370 whether payment for the service is to be made in
the manner previously recorded in the patient's history. If a different
mode of payment is selected, the system goes to the data change routine 54
to enter the new payment mode. If the same mode of payment is elected,
cross checks are done at 372 on entered and stored patient data to assure
that the transaction is authorized by the patient. At 374, the terminal
routine determines whether the medical claims are assigned by the patient
to the doctor, i.e. whether payment is made from the medical insurance
company directly to the doctor or whether the insurance company will pay
the patient who will pay the doctor. If the claim is unassigned, then the
operator confirms at 376 that payment by the insurance company should go
directly to the patient.
Once the payment mode has been determined, the routine determines at 380
whether the patient is the insured or a covered relative of the insured.
If it is indicated at 382 that the patient is a covered dependent of the
insured, then the patient's name, sex, and birth date are entered at 384.
At 390 the operator enters the type of activity that led to the office
visit, e.g. illness, pregnancy, or accident. If an illness is indicated,
the dates of office visits and the noted symptoms are entered at 392. If a
pregnancy is indicated, office visit and estimated conception dates are
entered at 394. If an accident is indicated, the operator enters the
office visit and accident dates and type of accident at 396.
At 400 the operator initiates a cycle to enter each type of medical
service(s) performed, e.g. consultation, disability, follow-up to prior
illness, hospitalization, job related, return to work examination,
emergency services, laboratory work, or professional courtesy. If a
medical consultation is indicated, the consulting physician's
identification number is indicated at 402. If the medical diagnosis is a
disability and claims for disability insurance are entered at 404, the
operator further indicates at 406 enters whether the disability is total
or partial and at 408 enters the beginning and ending dates of the
disability.
An indication that the office visit was a follow-up to a prior illness may
be entered at 410. If the patient is hospitalized, a hospitalization stay
is indicated at 412 and the dates of the stay are entered at 414. If the
office visit is indicated 416 as being job related, the nature of the job
related examination is entered such as a routine examination for potential
injury to due toxic substances in the work place, for continued ability to
perform high stress or mentally exacting job functions or the like.
If the office visit results in an indication that the patient can return to
work, the indication is entered at 420 and the date of return at 422. At
424, the operator indicates whether an disability was involved. If there
was a disability involved, the operator enters at 426 whether the
disability was job related, i.e. whether workman's compensation may be
involved. At 428 the operator enters whether the disability was total or
partial and at 430 the beginning and ending date of the disability.
At 440 the operator indicates whether an emergency procedure was performed.
If the bill is for laboratory work, an indication of the laboratory work
performed is entered at 442. If the medical services were performed as a
professional courtesy, i.e. no charge, that is indicated at 444.
After the operator has entered the description of the type of medical
services provided, the operator indicates at 450 whether additional
services were provided as a part of the office visit. If additional
services were provided, the program cycles one or more times through the
type of visit routines until all performed services are described. After
all types of services have been indicated, then at 452 the routine cycles
through a diagnosis entry procedure until each diagnosis is entered. If a
consultation only is made, that is indicated at 454. If diagnoses were
made by the physician, the diagnoses are entered at 456. For each
diagnoses, the treatment proced | | |
