Claim reimbursement valuation and remittance validation
A claim valuation engine is provided. The claim valuation engine enables a healthcare provider to accurately value an expected reimbursement of a claim from a payer based on a contract between the healthcare provider and the payer. Contract terms, code sets, fee schedules, and other valuation data is input into the engine. The engine receives a claim from a healthcare provider information system, locates a contract applicable for valuing the claim, correlates the claim attributes with the contract terms according to a hierarchy, and determines an expected reimbursement for each claim attribute or group of attributes. The claim valuation engine is further operable to determine contractual allowances, determine under and overpayments by validating remittances, and to simulate valuation of a contract by valuing a claim based on multiple sets of contract terms. The engine is further operable to generate output reports and post results to the healthcare provider information system.
1. A system comprising:
an input module operable to:
receive contract terms, rates, and criteria in association with a contract between a healthcare provider and a payer for valuing a claim;
build the contract from the contract terms including a priority level for each contract term to create a valuation hierarchy for the contract terms, a category to describe each contract term, and a valuation type that corresponds to a type of calculation to perform to value each contract term, rates, and criteria to enable matching of one or more of the contract terms with one or more claim attributes of a claim;
link the contract with the payer;
store the contract in a contracts repository as an existing contract; and
receive the claim comprising the one or more claim attributes;
a valuation table to include the one or more claim attributes, and contract terms of existing contracts and/or proposed contracts organized according to the valuation hierarchy;
a claim attribute extraction module operable to:
access the claim;
identify a payer responsible for payment of the claim;
read the one or more claim attributes from the claim; and
load the claim attributes into the valuation table;
a payer-contract mapping module coupled to the claim attribute extraction module operable to locate a contract linked to an identified payer;
a contract term extraction module coupled to the payer-contract mapping module operable to read the located contract and load contract terms associated with the identified payer in conjunction with one or more proposed contract terms of a proposed contract derived from the contract terms associated with the identified payer of the located contract into the valuation table according to the priority level of each contract term;
a simulation module coupled to the input module, the contract term extraction module, the claim attribute extraction module, and the valuation table, the simulation module to simulate valuation of the one or more proposed contract terms of the proposed contract in conjunction with one or more of the claim attributes to enable creation of another contract for the identified payer based on a valuation of one or more of the claim attributes with one or more of the contract terms associated with the identified payer of the located contract and the valuation of the one or more proposed contract terms of the proposed contract;
an attribute-term correlation module coupled to the valuation table operable to correlate claim attributes or groups of claim attributes with the contract terms included in the valuation table according to the priority level of each contract term, wherein the attribute-term correlation module operates to first correlate contract terms having a first priority value with the claim attributes included in the valuation table; and
a valuation module coupled to the valuation table operable to:
for a correlation made by the attribute-term correlation module:
value the claim attributes or groups of claim attributes that correlate with the contract terms of the located contract according to the valuation hierarchy and a valuation type;
generate an expected reimbursement value for the claim according to the contract terms of the located contract;
compare an actual reimbursement for the claim to the expected reimbursement value for the claim to identify a payment variance; and
generate an expected reimbursement value for the claim according to the one or more proposed contract terms of the proposed contract and the valuation type; and
a report module operable to generate a simulation report for one or more procedures associated with the claim that have a greater expected reimbursement value according to the contract terms of the located contract as compared to the expected reimbursement value for the claim according to the one or more proposed contract terms of the proposed contract.
2. The system of claim 1 , the report output module further operable to:
generate a valuation report comprising an expected reimbursement value for the claim; and
post the valuation report to a host system.
3. The system of claim 2 , wherein the valuation module is further operable to:
analyze a charge amount for each claim attribute or group of claim attributes and the value of each claim attribute or group of claim attributes; and
generate an allowance value for each claim attribute or group of claim attributes.
4. The system of claim 3 , further comprising a remittance validation module operable to:
access remittance information associated with the claim, wherein remittance information comprises a remitted amount for each claim attribute or group of claim attributes;
analyze the remitted amount for each claim attribute or group of claim attributes and the value of each claim attribute or group of claim attributes; and
determine a variance between a remitted amount for each claim attribute or group of attributes and the value of each claim attribute or group of claim attributes.
5. The system of claim 4 , wherein the report output module is further operable to:
generate a report comprising the generated allowance values;
generate a report comprising the determined variances between the remitted amount for each claim attribute or group of attributes and the value of each claim attribute or group of claim attributes; and
post the reports to the host system.
6. The system of claim 5 , the simulation module further operable to:
receive a selection of an existing set of hierarchical contract terms and an input of a proposed set of hierarchical contract terms, wherein the hierarchical contract terms define criteria for valuing a claim;
receive a selection of a claim comprising one or more claim attributes; and
load the existing set of hierarchical contract terms, the proposed set of hierarchical contract terms, and claim attributes into the valuation table for valuation by the valuation module.
7. The system of claim 6 , wherein the report output module is further operable to:
generate the simulation report comprising a value of each claim attribute or group of claim attributes based on the existing set of hierarchical contract terms and the proposed set of hierarchical contract terms; and
post the simulation report to the host system.