Systems and methods for processing medical claims
The system is an advanced, web-enabled, clearinghouse that facilitates efficient and effective claim routing, monitoring and report retrieval. A claim status summary is displayed that links directly to a rejected claim listing, wherein each rejected claim listed is a link to associated detailed claim information. The detailed claim information display has fields to edit the associated detailed claim information. During the editing process, a rules verification is performed against the edited claim information to ensure the edit comply with the known rules for the associated payer. Upon successfully completing the rules verification, the edited claim is submitted to a payer.
1. A computer-implemented method for providing information to medical providers regarding rejections of medical reimbursement claims, wherein medical reimbursement claims are submitted electronically from practice management computer systems of a plurality of medical providers to claims processing computer systems of a plurality of insurance payers for payment determinations, wherein an intermediary claim management system is in electronic communication between the practice management computer systems of the plurality of medical providers and the claims processing computer systems of the plurality of insurance payers, comprising the steps of:
receiving a medical reimbursement claim at the intermediary claim management system electronically from a practice management computer system of a particular medical provider, wherein the medical reimbursement claim includes data corresponding to an encounter between a patient and the particular medical provider;
submitting the medical reimbursement claim electronically from the intermediary claim management system to a claims processing computer system of a particular insurance payer for payment determination;
receiving a response at the intermediary claim management system from the claims processing computer system of the particular insurance payer for the medical reimbursement claim;
upon determination by the intermediary claim management system that if the response includes one or more claim rejection identifiers relating to specific issues in the medical reimbursement claim identified by the particular insurance payer:
retrieving a plurality of previously-received claim rejection identifiers from a claim management database associated with the intermediary claim management system, wherein the plurality of previously-received claim rejection identifiers were extracted from a plurality of prior responses received from the plurality of insurance payers corresponding to a plurality of prior medical reimbursement claims, and wherein each of the plurality of previously-received claim rejection identifiers comprises a unique format corresponding to its respective insurance payer;
comparing each claim rejection identifier in the response to the retrieved plurality of previously-received claim rejection identifiers;
matching each claim rejection identifier in the response to a corresponding previously-received claim rejection identifier from the plurality of prior responses corresponding to the plurality of prior medical reimbursement claims;
retrieving a corresponding predefined claim rejection description associated with each matched previously-received claim rejection identifier from the claim management database, wherein each predefined claim rejection description is generated via the intermediary claim management system based on historical data collected from the received plurality of prior responses comprising the plurality of previously-received claim rejection identifiers having the formats unique to each of the plurality of insurance payers, and wherein each predefined claim rejection description provides a standardized description of a respective specific issue in the medical reimbursement claim; and
storing the retrieved corresponding predefined claim rejection description in the claim management database in association with each claim rejection identifier for the medical reimbursement claim; and
providing each associated predefined claim rejection description for the medical reimbursement claim to the particular medical provider,
whereby the particular medical provider is able to determine if further action on the medical reimbursement claim is necessary as a function of the specific issues associated with the medical reimbursement claim.
2. The method of claim 1 , wherein the standardized description of the respective issue in each predefined claim rejection description is displayed in a human-understandable text format.
3. The method of claim 1 , wherein the step of matching each claim rejection identifier in the response to a corresponding previously-received claim rejection identifier and retrieving a corresponding predefined claim rejection description comprises linking each claim rejection identifier in the response with a corresponding previously-received claim rejection identifier and a corresponding predefined claim rejection description in a cross-referenced data structure in the claim management database for the medical reimbursement claim.
4. The method of claim 1 , wherein at least one of the specific issues in the medical reimbursement claim identified by the particular insurance payer comprises one or more of the following: missing information that is required for processing the medical reimbursement claim, inaccurate information in the medical reimbursement claim, an improper format for the medical reimbursement claim, information within the medical reimbursement claim that is internally discrepant, eligibility errors, duplicate claim errors, provider enrollment errors, coding errors, patient demographic errors, payer information errors.
5. The method of claim 4 , wherein information within the medical reimbursement claim is internally discrepant if at least two pieces of information are not permitted to coexist within the medical reimbursement claim based on a rule of the particular insurance payer.
6. The method of claim 1 , further comprising the step of, before submitting the medical reimbursement claim electronically from the intermediary claim management system to the claims processing computer system of the particular insurance payer for payment determination, determining if the medical reimbursement claim has any potential specific issues based on rules within the intermediary claim management system derived from previous issues associated with prior-received medical reimbursement claims, and if the medical reimbursement claim has one or more specific issues, presenting the medical reimbursement claim back to the particular medical provider for correction.
7. The method of claim 6 , wherein the step of presenting the medical reimbursement claim back to the particular medical provider comprises one or more of: flagging the one or more specific issues in the medical reimbursement claim that need to be corrected, sending an email notification to the particular medical provider, displaying information relating to the one or more specific issues to the particular medical provider on an interactive, web-accessible site generated and provided by the intermediary claim management system.
8. The method of claim 1 , wherein the step of providing each associated predefined claim rejection description for the medical reimbursement claim to the particular medical provider comprises one or more of: sending an email notification to the particular medical provider including each associated predefined claim rejection description, displaying each associated predefined claim rejection description on an interactive, web-accessible site generated by the intermediary claim management system.
9. The method of claim 1 , wherein each predefined claim rejection category falls under a predefined claim rejection category selected from the group comprising: eligibility errors, duplicate claim errors, provider enrollment errors, coding errors, patient demographic errors, payer information errors.
10. The method of claim 1 , wherein one or more of the claim rejection identifiers are proprietary to the particular insurance payer.
11. A computer-implemented method for processing medical reimbursement claims, wherein medical reimbursement claims are submitted electronically from practice management computer systems of the plurality of medical providers to claims processing computer systems of the plurality of insurance payers for payment determinations, wherein an intermediary claim management system is in electronic communication between the practice management computer systems of the plurality of medical providers and the claims processing computer systems of the plurality of insurance payers, comprising the steps of:
receiving a medical reimbursement claim at the intermediary claim management system electronically from a practice management computer system of a particular medical provider, wherein the medical reimbursement claim includes data corresponding to an encounter between a patient and the particular medical provider;
submitting the medical reimbursement claim electronically from the intermediary claim management system to a claims processing computer system of a particular insurance payer for payment determination;
receiving a response at the intermediary claim management system from the claims processing computer system of the particular insurance payer for the medical reimbursement claim;
upon determination by the intermediary claim management system that if the response includes one or more claim rejection identifiers relating to specific issues in the medical reimbursement claim identified by the particular insurance payer:
comparing each claim rejection identifier in the response to previously-received claim rejection identifiers stored in a claim management database associated with the intermediary claim management system to identify matches between claim rejection identifiers in the response and the previously-received claim rejection identifiers, wherein the previously-received claim rejection identifiers were extracted from a plurality of prior responses received from the plurality of insurance payers corresponding to a plurality of prior medical reimbursement claims, and wherein each of the previously-received claim rejection identifiers comprises a unique lexicon corresponding to its respective insurance payer;
upon determination that a match exists between a claim rejection identifier in the response and a previously-received claim rejection identifier, retrieving a corresponding predefined claim rejection description associated with the matched previously-received claim rejection identifier from the claim management database, wherein the predefined claim rejection description is generated via the intermediary claim management system based on historical data collected from the received plurality of prior responses that include the matched previously-received claim rejection identifier, and wherein the predefined claim rejection description provides a standardized description of a specific issue in the medical reimbursement claim in a proprietary lexicon unique to the intermediary claim management system; and
storing the retrieved corresponding predefined claim rejection description in the claim management database in association with the claim rejection identifier for the medical reimbursement claim; and
providing the associated predefined claim rejection description for the medical reimbursement claim to the particular medical provider,
whereby the particular medical provider is able to determine if further action on the medical reimbursement claim is necessary as a function of the specific issues associated with the medical reimbursement claim.
12. The method of claim 11 , wherein the proprietary lexicon comprises a human-understandable text format.