Abstract:
Systems, methods and computer program products for discouraging and preventing health care-related insurance fraud are disclosed. In an aspect, an insured (e.g., Medicaid) beneficiary identity validation eligibility verification tool is provided that identifies Medicaid beneficiaries using biometrics and verifies their Medicaid eligibility electronically each time they visit a health care provider who participates in the Medicaid program. In such an aspect, an electronic encounter record is created between the provider and the validated and verified beneficiary each time health care services are rendered. The tool of the present invention thus enables insurance companies, regulatory bodies and the like to match submitted claims to captured encounter records as proof that the beneficiary did visit the provider in question on the reported date of service.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This Application claims the benefit of, and is related to, Applicants&#39; co-pending U.S. Provisional Patent Application No. 61/158,385 titled “System and Method for Preventing Health Care Fraud,” filed on Mar. 8, 2009, which is incorporated by reference herein in its entirety. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    1. Field of the Invention 
         [0003]    The present invention generally relates to systems and method for preventing fraud, and, more specifically, to systems, methods and computer program products for discouraging and preventing health care-related insurance fraud. 
         [0004]    2. Related Art 
         [0005]    Health care fraud is the intentional deception or misrepresentation that an individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, the entity, or to some other party. Such benefit is often paid by a private insurance company or a public (i.e., state or federal) insurance program. 
         [0006]    The most common kind of health care-related fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of the amount of benefits payable. Fraudulent activities are almost invariably criminal, although the specific nature or degree of the criminal acts may vary from jurisdiction to jurisdiction. The variety of fraudulent reimbursement and billing practices in the health care area is potentially infinite. The most common fraudulent acts include: (1) billing for services, procedures and/or supplies that were never provided or performed; (2) the deliberate performance of medically unnecessary services for the purpose of financial gain; or (3) intentionally misrepresenting any of the following, for purposes of obtaining a payment—or a greater payment—to which one is not entitled:
       The nature of services, procedures and/or supplies provided or performed;   The dates on which services and/or treatments were rendered;   The medical record of service and/or treatment provided;   The condition treated or the diagnosis made;   The charges for services, procedures and/or supplies provided or performed; or   The identity of the provider or the recipient of services, procedures and/or supplies.       
 
         [0013]    Fraud continues to persist because, in 2007 for example, the United States spent more than $2.26 trillion on health care. Of that amount, The National Health Care Anti-Fraud Association (NHCAA)—a leading private-public partnership national organization—estimates conservatively that at least three percent (i.e., more than $68 billion) is lost to health care fraud. That amount is more than the gross domestic product (GDP) of 120 different countries. This enormous loss directly impacts patients, taxpayers and government through higher heath care costs, insurance premiums and taxes. Additionally, health care fraud often hurts patients who may be subjected to unnecessary or unsafe procedures or who may be the victims of identity theft. 
         [0014]    Given the foregoing, what are needed are systems, methods and computer program products for discouraging and preventing health care-related insurance fraud in ways superior to prior proposed solutions such as those described in, for example, U.S. Pat. Nos. 7,421,399 and 7,209,886, to Kimmel, which are each hereby incorporated by reference in their entirety. 
       SUMMARY OF THE INVENTION 
       [0015]    The present invention meets the above-identified needs by providing systems, methods and computer program products for discouraging and preventing health care-related insurance fraud. 
         [0016]    In one aspect, an insured (e.g., Medicaid) beneficiary identity validation and eligibility verification tool is provided that identifies Medicaid beneficiaries using biometrics and verifies their Medicaid eligibility electronically each time they visit a health care provider who participates in the Medicaid program. In such an aspect, the tool of the present invention is a web application executing on one or more web servers and accessible by a plurality of health care system participants (i.e., patients, providers, insurance administrators and the like) at various locations via various terminals. Further, in such an aspect, an electronic encounter record is created between the provider and the validated and verified beneficiary each time health care services are rendered. The tool of the present invention thus enables insurance companies, regulatory bodies and the like to match submitted claims to captured encounter records as proof that the beneficiary did visit the provider in question on the reported date of service. 
         [0017]    In an aspect, the present invention provides a method for preventing health care fraud that includes the steps of storing, in a central repository, a first biometric signature received from an insurance recipient during an enrollment period. Next, a first set of demographic information (i.e., social security number, photograph, insurance or Medicaid identification number, date of birth, name, address, Medicaid eligibility and the like) is received from the insurance recipient during the enrollment period and associating the first set of demographic information with the first biometric signature. Then, during a visit to a health care provider, a second biometric signature and a second set of demographic information is received from a patient. This is followed by the retrieval of the first biometric signature and the first set of demographic information from the central repository. The first and second sets of data are compared to verify the identity and insurance eligibility of the patient as the insurance recipient. This allows an encounter record to be created in the central repository, wherein the encounter records comprises a flag indicating the results of the comparisons. 
         [0018]    An advantage of the present invention is that it allows beneficiary identity to be established when the beneficiary is deemed insurance (e.g., Medicaid) eligible at an enrollment office; whereas prior art systems attempted to establish beneficiary identity when the patient visits a health care provider for the first time, where a patient&#39;s identity cannot typically be officially confirmed. 
         [0019]    Another advantage of the present invention is that when a beneficiary visits a health care provider, they “check-in” by scanning in their biometric signature which then can be sent to a central repository not only to be verified, but to also provide the health care provider&#39;s office with previously-stored (i.e., during enrollment) beneficiary demographic information (i.e., social security number, photograph, insurance or Medicaid identification number, date of birth, name, address, Medicaid eligibility and the like). 
         [0020]    Yet another advantage of the present invention is that it can be integrated with an insurance company or state Medicaid payment system. That is, when a medical claim is made to an insurance agency or state for payment, the respective claims system can make a request to the present invention&#39;s centralized server to verify that an encounter record exist for the provider/beneficiary interaction noted on the medical claim, thereby allowing a search of the associated central repository in order to respond with a “Yes” or “No” verification. 
         [0021]    Further features and advantages of the present invention, as well as the structure and operation of various aspects of the present invention, are described in detail below. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0022]    Various aspects and other aspects of this invention will be readily apparent from the detailed description below and the appended drawings, which are meant to illustrate and not to limit the invention, and in which: 
           [0023]      FIGS. 1-4  are block/dataflow diagrams of an exemplary beneficiary identity validation and eligibility verification system according to various aspects of the invention; and 
           [0024]      FIG. 5  is a block diagram of an exemplary computer system useful for implementing the present invention. 
       
    
    
     DETAILED DESCRIPTION 
       [0025]    The present invention is directed to systems, methods and computer program products for discouraging and preventing health care-related insurance fraud. 
         [0026]    In an aspect of the present invention, a Medicaid beneficiary identity validation and eligibility verification tool is provided that identifies beneficiaries using biometrics and verifies their eligibility each time they visit a health care provider. The present invention is now described in more detail herein in terms of this context. This is for convenience only and is not intended to limit the application of the present invention. In fact, after reading the following description, it will be apparent to those skilled in the relevant art(s) how to implement the following invention in alternative aspects (e.g., in the context of a private insurer, a different public insurance program, and the like). 
         [0027]    Referring to  FIG. 1 , a block diagram of an exemplary beneficiary identity validation and eligibility verification system and enrollment process, according to an aspect of the invention, is shown. In such an aspect, the following enrollment process may occur:
       1. A recipient visits a state Medicaid office, deemed Medicaid eligible, and is provided with a valid Medicaid ID;   2. The personal information of the newly-recognized Medicaid recipient (e.g., Social Security Number (SSN), Medicaid ID, date of birth, name, address and the like) is keyed into a web application executing at least partially on a web server  116  via a medical enrollment station  110 ;   3. The Medicaid recipient provides biometric signature to the web application;   4. The Medicaid recipient&#39;s photograph is taken and submitted to the web application; and   5. All of the information/data referenced above is transferred via a network (e.g., global, public Internet  112 ), and stored in a central database repository  118 .       
 
         [0033]    Referring to  FIG. 2 , a block diagram of an exemplary beneficiary identity validation and eligibility verification system and identity validation/eligibility verification process, according to an aspect of the invention, is shown. In such an aspect, the following identity validation/eligibility verification process may occur:
       1. The Medicaid recipient goes to a provider&#39;s location (i.e., a medical provider&#39;s office  102 , hospital  104 , clinic  106  or mobile unit  108 ) where an intake coordinator is logged into the web application; the Medicaid recipient then provides his/her Medicaid ID, SSN, date of birth, and biometric signature to the web application;   2. The collected information is inputted into the web application and transmitted over a network (e.g., the Internet  112 ) to central database repository  118 ; the web application then performs a search using the recipient information in order to find a unique match within database  118 ;   3. If a match is found within database  118 , then the web application returns information (via one of terminals  102 - 108 ) pertaining to the recipient such as their demographics, Medicaid eligibility and photograph;   4. If a match is not found, then a message is returned to the intake coordinator (via one of terminals  102 - 108 ) stating that the recipient is not present in database  118 ; and   5. If a match is found, but a different biometric signature is associated within database  118 , the event is logged and the web application returns a message to the intake coordinator stating that a biometric mismatch has occurred.       
 
         [0039]    Referring to  FIG. 3 , a block diagram of an exemplary beneficiary identity validation and eligibility verification system and encounter capture process, according to an aspect of the invention, is shown. In such an aspect, the following encounter capture process may occur:
       1. If a match is found in database  118  during the validation/eligibility verification process described in connection with  FIG. 2  using Medicaid ID, SSN, DOB and biometric signature, an encounter record is created in central database repository  118  denoting that the recipient (with unique recipient ID) visited the provider (with specific provider ID) on a particular date; and   2. If a match is found in database  118  during the validation/eligibility verification process described in connection with  FIG. 2  using Medicaid ID, SSN and DOB, but the biometric ID is different, then an encounter record is created in central database repository  118  denoting that the recipient (with unique recipient ID) visited the provider (with specific provider ID) on a particular date. A flag, however, is also set within the record which denotes that the identity of the recipient was not verified.       
 
         [0042]    Referring to  FIG. 4 , a block diagram of an exemplary beneficiary identity validation and eligibility verification system and encounter claim compare process, according to an aspect of the invention, is shown. In such an aspect, the following encounter claim compare process may occur:
       1. A state&#39;s Medicaid claims processing system (shown as state Medicaid Management Information System  122   a - n  in  FIG. 4 ) creates an extract file of claims which consists of records that contain the unique claim number, provider ID, recipient ID, and dates of service;   2. The extract file is transmitted to central database repository  118  where, in one aspect, the connection between a state&#39;s system  122  and central database repository  118  is a “private” point-to-point telecommunications connection via a private data network  120 ;   3. The web application creates a copy of the extract file that will be transmitted back to the state&#39;s Medicaid claims processing system  122  consisting of the unique claim number, provider ID, recipient ID, and flag information;   4. For each record in the original extract file, the web application searches central database repository  118  for a matching encounter record;   5. If a matching encounter record is found, the web application modifies the corresponding flag information for the specific record to be “yes”;   6. If a matching encounter record is not found, the web application modifies the corresponding flag information for the specific record to be “no”;   7. Each record in the extract file is checked for a matching encounter record until all of the records have been checked; and   8. Once complete, the web application sends the file containing the flag information back to the state&#39;s Medicaid claims processing system  122  using the point-to-point telecommunications connection via a private data network  120 .       
 
         [0051]    As will be appreciated by those skilled in the relevant art(s) after reading the description herein, in an aspect, the web application described above executes on one or more web servers  116  (as shown in  FIGS. 1-4 ) providing one or more websites which send out web pages in response to Hypertext Transfer Protocol (HTTP) or Hypertext Transfer Protocol Secured (HTTPS) requests from remote browsers. Thus, such web servers  116  are able to provide a graphical user interface (GUI) to users of the beneficiary identity validation and eligibility verification system in the form of web pages. These web pages are sent to user&#39;s desktop, laptop, mobile device, PDA or like terminal devices (at locations  102 - 110  and  122 ), and result in the GUI screens being displayed. 
         [0052]    As will also be appreciated by those skilled in the relevant art(s) after reading the description herein, in an aspect, the traffic between the web application&#39;s executing on web server  116  and all other components of the beneficiary identity validation and eligibility verification system shown in  FIGS. 1-4  is routed through one or more firewalls (shown as firewalls  114   a - c ) configured such that only authorized connections can gain access to the system&#39;s data. The purpose of the firewall is to provide security and restrict unauthorized access to the system and the patient data stored and processed therein. 
         [0053]    As will also be appreciated by those skilled in the relevant art(s) after reading the description herein, in an aspect, an application service provider (i.e., an entity providing the infrastructure for one or more health care providers, insurers and/or recipients) with multiple locations at one or more corresponding URLs) may allow access, on a paid subscriber/membership, and/or pay-per-use basis, to the tools (i.e., web application) the present invention provides for performing beneficiary identity validation and eligibility verification. 
       Exemplary Implementation 
       [0054]    The present invention (i.e., the process steps described above with reference to  FIGS. 1-4 , and the systems and methods for discouraging and preventing health care-related insurance fraud described above, or any part(s) or function(s) thereof) may be implemented using hardware, software or a combination thereof and may be implemented in one or more computer systems or other processing systems. However, the manipulations performed by the present invention were often referred to in terms, such as “selecting” or “documenting,” which are commonly associated with mental operations performed by a human operator. No such capability of a human operator is necessary, or desirable in most cases, in any of the operations described herein which form part of the present invention. Rather, the operations are machine operations. Useful machines for performing the operation of the present invention include general purpose digital computers or similar devices. 
         [0055]    In fact, in one aspect, the invention is directed toward one or more computer systems capable of carrying out the functionality described herein. An example of a computer system  500  is shown in  FIG. 5 . 
         [0056]    Computer system  500  includes one or more processors, such as processor  504 . The processor  504  is connected to a communication infrastructure  506  (e.g., a communications bus, cross-over bar, or network). Various software aspects are described in terms of this exemplary computer system. After reading this description, it will become apparent to a person skilled in the relevant art(s) how to implement the invention using other computer systems and/or architectures. 
         [0057]    Computer system  500  can include a display interface  502  that forwards graphics, text, and other data from the communication infrastructure  506  (or from a frame buffer not shown) for display on the display unit  530 . 
         [0058]    Computer system  500  also includes a main memory  508 , preferably random access memory (RAM), and may also include a secondary memory  510 . The secondary memory  510  may include, for example, a hard disk drive  512  and/or a removable storage drive  514 , representing a floppy disk drive, a magnetic tape drive, an optical disk drive, etc. The removable storage drive  514  reads from and/or writes to a removable storage unit  518  in a well known manner. Removable storage unit  518  represents a floppy disk, magnetic tape, optical disk, etc. which is read by and written to by removable storage drive  514 . As will be appreciated, the removable storage unit  518  includes a computer usable storage medium having stored therein computer software and/or data. 
         [0059]    In alternative aspects, secondary memory  510  may include other similar devices for allowing computer programs or other instructions to be loaded into computer system  500 . Such devices may include, for example, a removable storage unit  522  and an interface  520 . Examples of such may include a program cartridge and cartridge interface (such as that found in video game devices), a removable memory chip (such as an erasable programmable read only memory (EPROM), or programmable read only memory (PROM)) and associated socket, and other removable storage units  522  and interfaces  520 , which allow software and data to be transferred from the removable storage unit  522  to computer system  500 . 
         [0060]    Computer system  500  may also include a communications interface  524 . Communications interface  524  allows software and data to be transferred between computer system  500  and external devices. Examples of communications interface  524  may include a modern, a network interface (such as an Ethernet card), a communications port, a Personal Computer Memory Card International Association (PCMCIA) slot and card, etc. Software and data transferred via communications interface  524  are in the form of signals  528  which may be electronic, electromagnetic, optical or other signals capable of being received by communications interface  524 . These signals  528  are provided to communications interface  524  via a communications path (e.g., channel)  526 . This channel  526  carries signals  528  and may be implemented using wire or cable, fiber optics, a telephone line, a cellular link, an radio frequency (RF) link and other communications channels. 
         [0061]    In this document, the terms “computer program medium” and “computer usable medium” are used to generally refer to media such as removable storage drive  514 , a hard disk installed in hard disk drive  512 , and signals  528 . These computer program products provide software to computer system  500 . The invention is directed to such computer program products. 
         [0062]    Computer programs (also referred to as computer control logic) are stored in main memory  508  and/or secondary memory  510 . Computer programs may also be received via communications interface  524 . Such computer programs, when executed, enable the computer system  500  to perform the features of the present invention, as discussed herein. In particular, the computer programs, when executed, enable the processor  504  to perform the features of the present invention. Accordingly, such computer programs represent controllers of the computer system  500 . 
         [0063]    In an aspect where the invention is implemented using software, the software may be stored in a computer program product and loaded into computer system  500  using removable storage drive  514 , hard drive  512  or communications interface  524 . The control logic (software), when executed by the processor  504 , causes the processor  504  to perform the functions of the invention as described herein. 
         [0064]    In another aspect, the invention is implemented primarily in hardware using, for example, hardware components such as application specific integrated circuits (ASICs). Implementation of the hardware state machine so as to perform the functions described herein will be apparent to persons skilled in the relevant art(s). 
         [0065]    In yet another aspect, the invention is implemented using a combination of both hardware and software. 
         [0066]    In general, computer-readable memory media applied in association with aspects of the invention described herein may include any memory medium capable of storing instructions executed by a programmable apparatus. Where applicable, method steps described herein may be embodied or executed as instructions stored on a computer-readable memory medium or memory media. These instructions may be software embodied in various programming languages such as C++, C, Java, PHP, and/or a variety of other kinds of software programming/scripting languages that may be applied to create instructions in accordance with aspects of the invention. 
       CONCLUSION 
       [0067]    It is to be understood that the figures and descriptions of the invention have been simplified to illustrate elements that are relevant for a clear understanding of the invention, while eliminating, for purposes of clarity, other elements. Those of ordinary skill in the art will recognize, however, that these and other elements may be desirable. However, because such elements are well known in the art, and because they do not facilitate a better understanding of the invention, a discussion of such elements is not provided herein. It should be appreciated that the figures are presented for illustrative purposes and not as construction drawings. Omitted details and modifications or alternative aspects are within the purview of persons of ordinary skill in the art. 
         [0068]    It can be appreciated that, in certain aspects of the invention, a single component may be replaced by multiple components, and multiple components may be replaced by a single component, to provide an element or structure or to perform a given function or functions. Except where such substitution would not be operative to practice certain aspects of the invention, such substitution is considered within the scope of the invention. 
         [0069]    Variations, modifications, and other implementations of what is described herein will occur to those of ordinary skill in the relevant art(s) without departing from the spirit and scope of the invention. 
         [0070]    The examples presented herein are intended to illustrate potential and specific implementations of the invention. It can be appreciated that the examples are intended primarily for purposes of illustration of the invention for those skilled in the relevant art(s). There may be variations to these diagrams or the operations described herein without departing from the spirit of the invention. For instance, in certain cases, method steps or operations may be performed or executed in differing order, or operations may be added, deleted or modified. 
         [0071]    Furthermore, whereas particular aspects of the invention have been described herein for the purpose of illustrating the invention and not for the purpose of limiting the same, it will be appreciated by those of ordinary skill in the art that numerous variations of the details, materials and arrangement of elements, steps, structures, and/or parts may be made within the principle and scope of the invention without departing from the invention as described herein. 
         [0072]    Further, the purpose of the foregoing Abstract is to enable the U.S. Patent and Trademark Office and the public generally, and especially the scientists, engineers and practitioners in the relevant art(s) who are not familiar with patent or legal terms or phraseology, to determine quickly from a cursory inspection the nature and essence of this technical disclosure. The Abstract is not intended to be limiting as to the scope of the present invention in any way.