Method and system for adjudicating claims in a health services environment
Methods and systems for adjudicating claims in health services environments are presented. An exemplary method for processing service provider claims for payment includes scheduling appointments with service providers, receiving claims from the service providers, determining whether at least one scheduled appointment corresponds with at least one received claim and determining that at least one scheduled appointment has not been identified as corresponding to at least one received claim within a predetermined period of time. Optionally, the method includes presenting the particular received claim for payment when at least one of the scheduled appointments corresponds to the particular received claim.
1. A system for determining the appropriateness of service provider claims for payment, comprising:
a scheduling module configured to schedule appointments with service providers;
a claim intake module configured to receive claims from the service providers;
an adjudication module configured to match at least one scheduled appointment with at least one received claim and present at least one received claim for payment upon matching the at least one received claim to a scheduled appointment; and
a claims acquisition module configured to determine that at least one scheduled appointment has not been identified as corresponding to at least one received claim within a predetermined period of time.
2. The system of claim 1 wherein the claims acquisition module is further configured to determine a plurality of received claims associated with a particular scheduled appointment and queue the particular scheduled appointment for resolution when the adjudication module has matched the particular scheduled appointment with fewer than the plurality of received claims.
3. The system of claim 1 wherein the claims acquisition module is further configured to determine a type of claim that is anticipated for each scheduled appointment.
4. The system of claim 1 wherein the claims acquisition module is further configured to determine a number of claims that are anticipated to be recovered from a scheduled appointment.
5. The system of claim 1 wherein the claims acquisition module maintains a working list of appointments for which at least one claim is expected.
6. The system of claim 5 wherein the claims acquisition module is configured to update the adjudication module associating an appointment in the list with at least one received claim.
7. The system of claim 1 further comprising a claim tracking module configured to route unmatched claims from the adjudication module to at least one trouble shooter for resolution.
8. A method for determining the appropriateness of service provider claims for payment, in a computer system, comprising:
scheduling appointments, in the computer system, with service providers;
receiving claims, in the computer system, from the service providers;
determining, in the computer system, whether at least one scheduled appointment can be matched with at least one received claim;
determining, in the computer system, that at least one scheduled appointment has not been identified as corresponding to at least one received claim within a predetermined period of time; and
presenting the particular received claim for payment when at least one of the scheduled appointments corresponds to the particular received claim.
9. The method of claim 8 including the further step of matching at least one scheduled appointment with at least one received claim.
10. The method of claim 8 , including the further step of flagging a received claim for resolution when none of the scheduled appointments corresponds to the particular received claim.
11. The method of claim 8 , including the further step of determining a type of claim that is anticipated to match each scheduled appointment.
12. The method of claim 8 , including the further step of determining a number of claims that are anticipated to be recovered from a scheduled appointment.
13. The method of claim 8 , including the further step of maintaining a working list of appointments for which at least one claim is expected.
14. The method of claim 13 , including the further step of associating an appointment in the list with at least one received claim.
15. The method of claim 8 , including the further step of presenting at least one received claim for payment upon matching the at least one received claim to a scheduled appointment.
16. The method of claim 8 , including the further step of routing unmatched claims to at least one trouble shooter for resolution.
17. A system for determining the appropriateness of service provider claims for payment, comprising:
a scheduling module configured to schedule appointments with service providers;
a claim intake module configured to receive claims from the service providers;
an adjudication module configured to present at least one received claim for payment upon matching the at least one received claim to a scheduled appointment and present at least one received claim for payment upon matching the at least one received claim to a scheduled appointment; and
a claims acquisition module configured to determine that at least one scheduled appointment has not been identified as corresponding to at least one received claim.
18. The system of claim 17 further comprising a claim tracking module configured to route unmatched claims from the adjudication module to at least one trouble shooter for resolution.