Abstract:
The disclosed embodiments relate generally to a method and system identifying health care providers who are authorized to submit health care claims to health insurer or claims processor. Also provided is a system and method verifying that providers who submit claims are operated in location(s) attested and that those location(s) are legitimate sites for delivery of healthcare services. Utilized are novel algorithms to compare information from provider&#39;s credit card terminal to information commonly held by insurance company and identify beneficiaries and dependents who are eligible to receive services capturing health care encounter at point of service, and capturing location and time of health care encounter of authorized beneficiary or dependent at the authorized location of a provider. Further is a process and system to verify healthcare transaction seeking payment, submitted by the provider, which is matched against information created, and used to verify certain healthcare transactions for approval and/or payment.

Description:
FIELD OF THE INVENTION 
       [0001]    The present invention generally relates to a method and system of verifying health care claims made for payment, particularly to such a method and system wherein electronic health care encounter information is communicated from a transmitting device or machine to a data base. 
       BACKGROUND OF THE INVENTION 
       [0002]    According to the US Government General Accounting Office, approximately 10% of health care claims are fraudulent or abusive. This costs the United State between $125 Billion and $175 Billion annually. In a typical scenario, a provider (physician, pharmacy, medical equipment supplier, dentist, for example) submits a claim to a health insurer or their claim processor for payment of services rendered to an insured customer or member of the health plan. Because of the number of claims (billions annually) and the number of providers (millions) who are authorized to submit claims to government sponsored and private health plans, it has been impossible prior to this invention to independently verify that a recipient or beneficiary or member of a health plan was in the provider office when the claim, submitted as a separate process, stipulates. 
         [0003]    Prior to any payment, the provider submitting the claim (physician, pharmacy, dentist, optometrist, etc) must be authorized by the health plan or paying authority to submit claims for payment. Also, the claim submitted by the provider must have the identification (health plan member number) of the health plan member. When the claim is submitted, certain information must be in order for the claim to be paid. Claims must contain the identification of the provider authorized to deliver the product or service, the name and plan identification of the health plan member or insured; the date the service was provided and description of the service provided or product delivered (such as durable medical equipment) which is indicated by a code. 
         [0004]    In addition, the recent proliferation of web portals has made it easier to commit fraud and abuse. Since claim information sometimes only requires a legitimate provider identification and legitimate insured identification, such as a Social Security Number for Medicare recipients, researching that information on web portals has made false claims easier to file and be paid. 
         [0005]    Health care claims, in order to be paid, contain information on 1) the provider who is submitting the claim and wishes to be paid; 2) the insured individual to whom the medical product was delivered or service rendered, 3) the date of service of the treatment or product delivery, and 4) details and codes describing the service or product rendered. Fraudulent claims can be easily submitted and paid. 
         [0006]    Thus, there still remains in the art a need for solving the problems associated with fraud and abuse in health care services. 
       SUMMARY OF THE INVENTION 
       [0007]    The present invention provides for solving the problems associated with fraud and abuse in health care services. This invention can verify that certain aspects of the healthcare claim can be verified prior to payment. Disclosed is a system and method that creates a “risk profile”, or the likelihood that the healthcare provider is submitting fraudulent or abusive claims, based on information from their 1) credit card terminal, 2) their willingness to participate and give us information (behavioral information) 3) changes in billing data, numbers of addresses and billing numbers on file (may be legitimate, but a risk element nonetheless) and 4) comparison of these data to claims that the provider submits. 
         [0008]    The present invention provides a method and system of identifying health care providers who are authorized to submit health care claims to a health insurer or claims processor. The system and method verifies that healthcare providers who submit claims are operate in the location[s] that they attest to and that those locations are legitimate sites for the delivery of healthcare services. Information is compared from a provider&#39;s credit card terminal to information commonly held by an insurance company. Beneficiaries and their dependents are identified who are eligible to receive health care services and a health care encounter at the point of service is captured as well as the location and time of a health care encounter of an authorized beneficiary or dependent at the authorized location of a health care provider. 
         [0009]    The invention further provides a process and system to verify that a healthcare transaction that is seeking payment is submitted by a health care provider that can be matched against information on the encounter created by this invention. The created information is so used to verify certain healthcare transactions for approval and/or payment. 
         [0010]    In one embodiment, the invention generally relates generally to a method of verifying health care claims made for payment, particularly to such a method wherein electronic health care encounter information is communicated from a transmitting device or machine to a data base. 
         [0011]    The verification card system is comprised of at least one identification card issued to a health care provider having a unique number encoded on it, the number comprising a banking identification number corresponding to the verification card system, and at least one identification card issued to a health care plan member or beneficiary or recipient having a unique number encoded on it, the number comprising a banking identification number corresponding to the verification card system, means for receiving health care product or service code information from an existing point-of-sale device when the provider card and/or the recipient card is swiped through the point-of-sale device, a means for converting that code into a code of field which can be read by health care claims payment systems, a means for storing and accessing the unique card numbers of health care providers and verifying that the provider to whom that card is assigned is eligible to provide products and services to the patient or family member whose card is also swiped, and identification numbers of swipe terminals and associating them with identifications of health care providers and a means for storing and accessing unique card numbers and associating them with health care plan members and their associated beneficiaries, a means for determining which types of swipe terminals may be authorized to send information to the computer system and be considered for payment; an means for comparing the information captured from the swipe[s] of provider and health plan member cards on the point-of-sale system with a claim submitted by the authorized health care provider, and a means to identify claims submitted by unauthorized health care providers and a means to identify claims submitted by health care providers where the recipient has not swiped a card in the office of the provider submitting the claim. 
         [0012]    In another embodiment, the verification system is comprised of at least one identification card issued to a health care provider having a unique number encoded on it, the number comprising a banking identification number corresponding to the verification card system, and at least one identification card issued to a health care plan member or beneficiary or recipient having a unique number encoded on it, the number comprising a banking identification number corresponding to the verification card system, means for receiving health care product or service code information from an existing point-of-sale device when the provider card and/or the recipient card is swiped through the point-of-sale device, a means for converting that code into a code of field which can be read by health care claims payment systems, a means for storing and accessing the unique card numbers of health care providers and verifying that the provider to whom that card is assigned is eligible to provide products and services to the patient or family member whose card is also swiped, and identification numbers of swipe terminals and associating them with identifications of health care providers and a means for storing and accessing unique card numbers and associating them with health care plan members and their associated beneficiaries, a means for determining which types of swipe terminals may be authorized to send information to the computer system and be considered for payment; an means for comparing the information captured from the swipe[s] of provider and health plan member cards on the point-of-sale system with a claim submitted by the authorized health care provider, and a means to identify claims submitted by unauthorized health care providers and a means to identify claims submitted by health care provider&#39;s where the recipient has not swiped a card in the office of the provider submitting the claim. 
         [0013]    Depending on the implementation, the verification card system of the present invention may also comprise at least one magnetic stripe card associated with a patient or health plan member, a database relating the number of that card to the health plan identification number, and computer code to create from the card information and keystrokes on the point of sale device a query to the health plan computer system regarding information that health plan has on its system regarding that individual or their family, and a software-controlled system to allow or deny that swipe terminal to receive such information. The invention further comprises a method to allow the information to be displayed on a web browser of a provider authorized by the health plan to see such information. The invention also comprises a method to submit a health care claim from the information stored on the provider card, the provider swipe terminal, the health plan member card and a code entered into the point-of-sale system. The invention also comprises a method to store a code identifying the health plan that the card holder is covered by, and a method to update such information. 
         [0014]    The verification system may further comprise a computer system at least one identification card that office There is no verification that the service was ever rendered or that the insured was actually in the office or store of the provider claiming for payment. Insured are sometimes sent a benefits statement that lists claims made on their behalf, but increasingly these are electronic, made optional, and if they do not require payment by the insured, are ignored. 
         [0015]    The foregoing objects are achieved and other features and advantages of the present invention will become more apparent in light of the following detailed description of exemplary embodiments thereof, as illustrated in the accompanying drawings. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0016]    In the drawings, wherein similar reference characters denote similar elements throughout the several views: 
           [0017]      FIG. 1  shows a diagram of one embodiment of issuance of a provider card. 
           [0018]      FIG. 2  shows a diagram illustrating an embodiment of issuance of a health plan member card. 
           [0019]      FIG. 3A  illustrates one embodiment of a matching process. 
           [0020]      FIG. 3B  shows another illustration of a matching process. 
           [0021]      FIG. 4A  is a block diagram illustrating card networks. 
           [0022]      FIG. 4B  shows a block diagram illustrating a provider card terminal registration process. 
           [0023]      FIG. 4C  illustrates a block diagram showing one embodiment of portal access using a patient card. 
           [0024]      FIG. 5  shows a flow diagram of assignment of cards and establishment of database entries. 
           [0025]      FIG. 6  shows a flow diagram illustrating transaction capture at point of care. 
           [0026]      FIG. 7  shows a flow diagram illustrating data extract and matching process. 
           [0027]      FIG. 8A  shows a flow diagram illustrating one embodiment of the present invention. 
           [0028]      FIG. 8B  shows a flow diagram and is a continuation of  FIG. 8B . 
       
    
    
     DETAILED DESCRIPTION 
       [0029]    The invention will now be described in detail with reference to the accompanying drawings. The present invention relates to a healthcare claim verification system and method which allows for the verification of location, time and services or health care products delivered. The system and method also provides for matching of claims for payment submitted by health care providers. Further, the system and method provides for the ability to access additional information about the owner of the card, and process certain health care transactions from the point-of-sale terminal, and from a web browser from a provider authorized by the health plan with this invention. 
         [0030]    The system and method comprises a plurality of cards issued to providers and to a plurality of cards issued to health plan members, a sponsor bank processor, and a processing hub, which serves at the nerve center of the system. In order to achieve the desired functionality, the system uses the existing banking networks in a unique and novel way to gain access to virtually all existing retail point-of-sale (POS) devices, computers with POS interfacing, cash registers with POS interfacing and other similar devices which can be used to access the banking system. As used herein, POS device includes all such devices, and includes data entry which is effected both by swiping a care through the device and by manual entry. Further, the system incorporates a method to establish a relationship between a web browser and a POS terminal from an authorized health care provider. 
         [0031]    To access these POS devices, the operator of the system and method must apply for and obtain a Bank Identification Number (BIN) from the American Banking Association. The BIN serves as a unique identifier of the verification card system within the banking network. The BIN is encoded on a magnetic strip on each card in the system as a part of the card&#39;s identification number. Alternatively or additionally, the BIN and identification number can be encoded as a bar code, or provided by any other means known in the art. 
         [0032]    The BINs will be able to be read by the POS devices which are pre-programmed to recognize only certain types of cards, such as those from VISA®, MasterCard®, and American Express®. By using one of these numbers, the card will be recognized by almost all POS devices, and occurs regardless of the POS device used. 
         [0033]    Adverting to  FIG. 4A , each swipe terminal authorized to process credit and debit card transactions is installed by an independent third party and linked to their the identified in multiple ways. When a card is swiped the owner or lease personnel of the terminal is identified and available to the operator of the system along with the location of the swipe terminal. 
         [0034]    The processing hub also comprises a code to identify that the location is a street address, a mobile or wireless terminal, a terminal operating in a vehicle such as a Para transit vehicle that has been authorized to provide services to a health plan. In addition, the Terminal ID, an alphanumeric set of characters unique to each terminal, is available to the operator of the system, as is a Merchant Category Code (MCC) which identifies the industry sector and sub sector that the owner or lease personnel of the terminal operates in. 
         [0035]    As shown in  FIG. 1 , issuance of provider card, a plurality of health plans may contract with the operator of the verification system to issue magnetic stripe cards or card with a chip or the like, to the providers they authorized to submit claims and the members of their health plans. The cards are not limited to magnetic cards, smart cards with chips, or any other card or non-card medium, but include any type of medium that stores data. The use of the word “card” is meant to include one or more different types of mediums holding data. The cards are pre-assigned in the processing hub to the authorized providers. The processing hub will, depending on the embodiment, also contain the UPIN (Universal Provider Identification Number) for the provider for whom a card has been issued and the identification of the health plan[s] for which that provider is eligible to submit claims. If a provider is no longer eligible to submit claims to a health plan, that health plan identification will be removed from the provider record on the verification system. Health plan(s) system  100  is in communication with Verification processing hub  110  and Provider card  120 . Again, the invention is not limited to a magnetic card, but may include a smart card(chip) or any other medium containing data. Communication links are preferably data links. Such data link can alternatively be, but is not limited to, an electronic data link, optical fiber connection, wireless data connection or any other known connection used for data transfer, for example, over the internet as an email, text message or the like, including any other communication. Depending upon the implementation, communication link can operate in one or more modes of transmission. For example, such modes include radio frequency transmissions, optical transmission, microwave transmission, digital or analog transmission, or other known data transmission. 
         [0036]    The authorized provider will swipe the card in the POS terminal[s] and enter a pre-assigned code on the POS terminal and the information will be sent to the bank processing hub. The bank processing hub, through prior arrangement will pass the information to the verification processing system, which will capture the Terminal ID[s] for the authorized provider. Since providers may have multiple offices, the processing hub will allow the card to be swiped in multiple POS terminals. If the provider is already known to the verification processing system, and a health plan transmits to the system operator that a known provider is eligible to submit claims to that health plan, a record of such eligibility will be added to the verification processing hub. 
         [0037]    As shown in  FIG. 2 , issuance of a health plan member card, the health plans may also contract with the operator of the verification system to issue magnetic stripe cards or the like to the members of their health plan. The cards are pre-assigned and the processing hub will store the plan identification number with the unique BIN number. If the individual already has a card issued by the operator of the system, the operator can change, via software, the health plan which the card holder is receiving benefits from. There will be a one to one relationship between the health plan identification number and the BIN number of the card; although the plan identification number may represent that multiple individuals can receive health benefits. If the person assigned the card is no longer eligible to receive health care services from the health plan, it will be deactivated or the information about the health plan and plan identification number will be removed. Health plan(s) system  200  is in communication with verification processing hub  210  and member card  220 . Member card  220  is similar in description to member card  120 . 
         [0038]    When the card holder visits a health care provider, they swipe their card in the POS terminal at the provider location. The health care provider&#39;s POS system is connected to the financial network and the swipe information is routed to the processor of the bank issuing the BIN number of the card. Through an arrangement with the processor, the information is passed to the verification processing system. A pre-assigned code is entered into the POS terminal to instruct the verification processing system what to do with the information collected from the card swipe. 
         [0039]    In one embodiment, the processing hub is instructed to format a query to the health plan associated with the card to verify that medical products or services billed to the health plan in the name of the card owner or other individuals covered under the same plan identification of the card owner are eligible for reimbursement by the health plan. The verification processing system and method stores the Terminal ID of the originating POS terminal; said Terminal ID is transmitted as a usual and customary part of the swipe information delivered by the financial networks. The verification processing system further stores the time stamp of the swipe, which is also a usual and customary part of the swipe information delivered by the financial networks. 
         [0040]    The verification processing system maintains a record of each swipe including the unique card number, Terminal ID and time of the swipe. Since the verification processing system contains tables that relate the Terminal ID of the originating POS terminal to providers authorized to submit claims to the health plan; and the verification processing system stores the plan identification affiliated with the member card that was swiped, as well as the names of individuals covered under that same plan identification, the verification processing system also stores the name and UPIN for the provider associated with the Terminal ID and the name of the individual present to receive medical services or products. 
         [0041]    The verification processing system and method can also store the code for medical products or services rendered. The code for medical products or services rendered can represent a single product or procedure code, or can represent a set of products or procedure codes normally associated with each other. 
         [0042]    One embodiment of this system and method is a dental exam, which consists of three Common Dental Terminology (CDT) codes. When 1) a pre-defined code is entered with a card swipe of a health plan member card, and 2) the MCC of the terminal is that of a dental office and identified as such by the verification system; 3) the processing hub will complete an 837D claim form filling in the 3 CDT codes for a (routine) dental examination. All health plans operate a computer system for processing claims submitted by insured members and by authorized health care providers. The standard claim form, the HCFA 1500, as well as others, require that the claim contain the name and plan identification of the insured; the name and UPIN of the provider claiming payment for the&#39;product or service, the description of the product or service represented by a code for medical procedures (CPT or Common Procedural Terminology); for dental procedures (CDT or Common Dental Terminology); prescription drugs (NDC or National Drug Code); Durable Medical Equipment; and the date of service. These claims are either submitted to the health plan electronically in defined formats, or data entered into defined formats if submitted by paper. The health plan computer system processes the claim to determine whether it is eligible to be paid based on the specific coverage and payment or claim history of the individual. 
         [0043]    As shown in  FIGS. 3A-3B , in the preferred embodiment of the system, the operator of the verification system, which may be the health plan itself, will compare the information stored at the processing hub, namely provider name, patient name, product or service code, and date of service- to those fields from the corresponding claim. If there is not a record of the processing hub having such information, the health plan can deny or suspend payment pending further investigation.  FIG. 3A  shows Table 1 having provider names and related numbers and terminal identification.  FIG. 3B  shows a matching process between information in blocks  300  and  310 . The information is given as an example only within these blocks and is no means meant to limit the information contained within the blocks. 
         [0044]    In one embodiment of the system and method, the information from the swipe, patient name, product or service code, will be matched at a third location such as a pharmacy or medical supply house to verify that a legitimate prescription or certificate of medical necessity has been originated at a physician office prior to payment. Depending on the embodiment, the card number will be taken directly from the swipe information transmitted to the bank processing hub, and passed to the verification system after reading the BIN number. The verification system, having stored the health plan member and dependents names based on the process shown in  FIG. 2 , will create a record of that for the matching process. The Terminal ID of the swipe will be related to provider identification, which has been stored as a result of the process demonstrated in  FIG. 1 . 
         [0045]    Shown in FIGS.  4 A- 4 B- 4 C, when the health plan has provided a web (Internet) portal to its authorized providers, the providers may want to use the portal for one of a number of transactions; to see the information that the health plan has regarding the coverage of a health plan member, and/or to submit a claim on behalf of that plan member. When the member card is swiped in the provider office, a return code will be sent to the POS terminal, at the same time the processing hub will create a query to the web portal requesting information about the member whose card was swiped. The operator of the system will provide a web site into which the return code will be entered. The web site will store login instructions for the provider portal for the health plan designated in the member record illustrated in  FIG. 2 , and will sign the provider&#39;s browser onto the appropriate web site for the plan for which that member belongs. When the code is entered, the processing hub will format a web services query to the appropriate health plan web site and the results will be displayed on the web browser which entered the code. For purposes of this invention, “health plan” means any insurance, discount plan, specialty insurance for vision care, dental care, or similar specialty, whether offered by a private insurer or governmental entity. As shown in  FIG. 4A , block  400  registration with card networks provides owner or lessee of terminal  410 , street address of terminal  420 , terminal identification  430 , and merchant category code (MCC)  440 .  FIG. 4B , provider card terminal registration process, shows block  450  provider card in communication with block  460  bank processing hub and block  470  verification processing hub.  FIG. 4C  illustrates a portal access using patient card. Block  480  represents a card and terminal. Block  481  represents a member&#39;s card swiped at a POS terminal. Block  482  represents a bank processing hub. Block  483  represents a verification processing system. Block  484  represents a verification processing system and block  485  represents authorization key sent back to original POS terminal. All blocks are in communication with each other as previously described. 
         [0046]    Illustrated in  FIG. 5  through  FIG. 7  are block diagrams relating to the process outlined in  FIGS. 8A-8B ; Processing Hub Technical Details. The numbers illustrated in  FIGS. 5 through 7  related to the numbers shown in  FIGS. 8A-8B . The steps shown in  8 A- 8 B may be accomplished in any sequence. In  FIG. 5 , shown is an assignment of cards and establishment of database entries. Block  500  contains the process steps of step  1  in  FIGS. 8A-8B . Block  501  contains the process steps of steps  2 , and  5  in  FIGS. 8A-8B . Block  502  contains the process steps of step  3  in  FIGS. 8A-8B . Block  503  contains the process steps of steps  4  and  6  in  FIGS. 8A-8B . Blocks  500 ,  501 ,  502 , and  503  are in communication with each other as previously described. The processing hub of the present invention provides front-end POS device management and message processing for card authorization. The processing hub can be implemented using and computer and acceptable storage and processing capacity. The processing hub will have communications with a processor which communicates directly with the financial networks and devices.  FIG. 6  illustrates a transaction capture at the point of care. Block  600  contains the process steps of steps  7  and  11  in  FIGS. 8A-8B . Block  601  contains the process steps of step  8  in  FIGS. 8A-8B . Block  602  contains the process steps of step  9  in  FIGS. 8A-8B . Block  603  contains the end of process steps if the answer to block  602  is NO. If block  602  is YES, then block  604  presides. Block  604  contains the process step of step  10  in  FIGS. 8A-8B . Blocks  600  through  604  are in communication with each other.  FIG. 7  illustrates a data extract and matching process. Block  700  contains the process steps of step  11  in  FIGS. 8A-8B . Block  701  contains the process steps of step  12  in  FIGS. 8A-8B . Block  702  contains the process steps of step  10  in  FIGS. 8A-8B . Block  703  contains the process steps of step  13  in  FIGS. 8A-8B . Blocks  700  through  703  are in communication with each other. Depending on the implementation, blocks  700  and  702  are fed into block  701 .  FIG. 8A-8B  illustrate one embodiment of a process using the invention. While the verification system herein described constitutes the preferred embodiment of the present invention, it is to be understood that the invention is not limited to this precise form of system and the changes may be made therein without departing from the scope of the inventions which is defined in the claims. 
         [0047]    In one embodiment at least one card issued to a provider authorized by a health plan to claim payment for products or services, having a magnetic stripe, memory chip card (SmartCard) or the like, and having a unique identification number approved by the American Banking Association for use in a banking network, said identification number corresponding to the Universal Provider Identification Number of the provider. The at least one issued card is given to an individual to identify them as a member of a health plan to claim payment for products or services, the card having a magnetic stripe, memory chip or the like and having a unique identification number approved by the American Banking Association for use in a banking network, has an identification number corresponding to the current Identification Number of the individual other covered by the same Identification Number given by a health plan. A verification hub also contains a method to determine the health plan that the member belongs to. 
         [0048]    In one embodiment, a bank processing hub computer under bank hub software control and in communication of a credit and debit card network with a pre-existing standard retail point of sale devices has the bank processing hub computer receiving provider, member, Terminal ID and time stamp information when said individual card is swiped, with the bank processing system recognizing the BIN number of the provider card and individual card and communicating the details of the swipe transaction to the verification processing hub. 
         [0049]    Depending on the implementation, a verification processing system that the Bank processing hub communicates the swipe details to, and stores the swipe details has a process as follows. The verification processing system stores the identification of health plans that the provider is eligible to submit claims for payment of services rendered. Further the verification hub also stores the tables that relate the unique card number to the health plan[s] and the health plan identification number; the verification processing system stores the unique card number related to the Terminal ID, MCC (Merchant Category Code) and UPIN of the provider, stores the health plan and health plan identification associated with the unique card, stores any other information necessary to submit health care transactions. Further, the verification hub contains logic to perform certain actions based on the combination of any or all of the data elements stored and data elements transmitted from a card swipe, including codes sent from the POS terminal. 
         [0050]    The verification processing system contains a novel method to compare the information generated from the card swipes, specifically the identification of the provider, the identification of the individual receiving services, the billing unit, as express in common industry terminology such as procedures (CPT or Common Procedural Terminology); for dental procedures (CDT or Common Dental Terminology); prescription drugs (NDC or National Drug Code); Durable Medical Equipment; and the date of service; with the same information on a claim received for payment by a health plan. 
         [0051]    Other alternative embodiments or implementations according to the various teachings of the present invention will be understood by those skilled in the art and are achieved without departing from the spirit and scope of the invention. It is therefore intended that the present invention is not limited to the disclosed embodiments described herein.