Abstract:
An automated system and method for calculating healthcare provider claims metrics and generating reports comprising claims metrics. The automated system and method facilitates provider claims analysis for providers that belong to a healthcare system or network. A computer user enters identifying information for a healthcare provider (such as a tax identification number). The healthcare provider identifying information may be used to generate a report for the individual provider and a system report for the system or network to which the provider belongs. Each report comprises a plurality of metrics related to claims processed for the provider by a healthcare benefits company. The report provides numerous metrics and details regarding the claims processed by the healthcare benefits company. By reviewing the data and additional processing tips, the healthcare provider may identify ways to increase the number of successfully processed claims in a particular time period and to improve its business operations.

Description:
FIELD OF THE INVENTION 
       [0001]    The present invention relates to automated document generation. In particular, the present invention relates to automated system and method for generating a healthcare provider claims summary. 
       BACKGROUND OF THE INVENTION 
       [0002]    Providers of medical and health services typically rely on third-party insurers to receive payment for the services they provide to patients. The payment process typically involves submission of a claim from the provider to the insurer requesting a payment, adjudication of the claim by the insurer to determine a level of payment, and remittance of a payment from the insurer to the provider according to the adjudicated claim. High volume providers may submit numerous claims each month to many different insurers to receive payments for the services they provide to their patients. 
         [0003]    The amount paid by each insurer to the provider for each service depends upon various factors including the level of insurance coverage for specified medical services and products. Many insurers offer numerous insurance plans to consumers and therefore, provide varying levels of coverage. As a result, the provider&#39;s payment for the same procedure performed on two different patients may vary according to the coverage under each patient&#39;s insurance plan. 
         [0004]    In addition to offering different types of insurance plans and levels of coverage, every insurer typically establishes its own criteria for completing and submitting claims. The criteria related to the content of a claim as well as the submission process may be stringent. The insurer may decline claims that fail to meet its specific criteria for content and submission. When the claim is declined, the provider must correct the deficiency or deficiencies in the claim and resubmit it. Every rejection of the claim from the insurer delays the payment and increases the provider&#39;s administrative costs. 
         [0005]    Because the provider may interact with numerous insurers offering numerous plans and levels of coverage as well as claims submission requirements, it can be difficult for the provider to determine the extent of its interactions with each insurer. For example, the provider may not know the number of claims it processes each month with each insurer, the “success rate” for claims, the “decline rate” for claims, or the amounts paid by the insurer. Such information, however, may be of great value to the provider. Claims processing “metrics” may allow the provider to determine its administrative or overhead costs and more importantly, assist the provider in reducing its administrative or overhead costs with a particular insurer. The ability to compare metrics over a period a time may further assist the provider in determining which cost reduction efforts are effective. A reduction in administrative overhead and costs may allow the provider to devote more time and resources to patient care. 
         [0006]    Although administrative metrics for claims may be useful to a provider, obtaining such metrics can be difficult. The provider may have the information it needs to calculate the metrics but the required data may not be centrally located or readily accessible. Furthermore, the provider may not have the knowledge or tools to calculate the metrics. By devoting time and resources to the effort, the data collection and calculation processes further increase the provider&#39;s administrative costs and burden. 
         [0007]    For providers that operate multiple facilities or that are part of an extensive health network, collecting claims data across facilities and calculating the metrics can be particularly challenging. The provider may not know how or where all of the information it needs to calculate metrics across facilities is stored. In addition, the provider is unlikely to have any tools to facilitate the data collection and analysis or to even understand, once the data has been collected, how the calculations should be performed. There is a need for an automated system and method for calculating provider claims metrics and generating reports comprising provider claims metrics. There is a need for an automated system and method for calculating provider claims metrics for providers that are part of a health care system or network. 
       SUMMARY OF THE INVENTION 
       [0008]    The present disclosure describes an automated system and method for calculating provider claims metrics and generating reports comprising provider claims metrics. The automated system and method facilitates provider claims analysis for providers that belong to a healthcare system or network. In an example embodiment, a computer user enters identifying information for a healthcare provider (such as a tax identification number (TIN)). The healthcare provider identifying information may be used to generate a report for the individual provider and a system report for the system or network to which the provider belongs. TINs may be linked using a system generated identifier. 
         [0009]    Reports are generated based on TINs or other provider identifiers selected by a computer user. Reports may be generated for individual providers or for an entire system or network. Each report comprises a plurality of metrics related to claims processed for the provider by a healthcare benefits company or insurer. The report provides numerous metrics and details regarding the claims processed by the healthcare benefits company. By reviewing the data and additional processing tips from the healthcare benefits company, the provider may identify ways to increase the number of successfully processed claims in a particular time period and to improve its business operations. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0010]      FIG. 1A  is a diagram of a daily claims data process according to an example embodiment; 
           [0011]      FIG. 1B  is a diagram of a daily non-claims data process according to an example embodiment; 
           [0012]      FIG. 2A  is a sample taxpayer identification number (TIN) document type page according to an example embodiment; 
           [0013]      FIG. 2B  is a sample name document type page according to an example embodiment; 
           [0014]      FIG. 2C  is a sample summary by name report list page according to an example embodiment; 
           [0015]      FIG. 3A  is a sample claims summary report page according to an example embodiment; 
           [0016]      FIG. 3B  is a sample claims details report page according to an example embodiment; 
           [0017]      FIG. 3C  is a sample reprocessed claims report page according to an example embodiment; and 
           [0018]      FIG. 3D  is a sample inquiries report page according to an example embodiment. 
       
    
    
     DETAILED DESCRIPTION 
       [0019]    In an example embodiment, data for provider claim metrics may be located in a plurality of computer systems that support claims processing for numerous providers. Example computer systems are identified in Table 1. 
         [0000]    
       
         
               
             
               
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 Computer Systems 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Claims 
                 CAS 
                 Claims and subscriber management system that 
               
               
                 Administration 
                   
                 contains information on members, providers, 
               
               
                 System 
                   
                 and group benefits. 
               
               
                 Contract 
                 CIS 
                 System for administering provider contracts. 
               
               
                 Information 
               
               
                 System 
               
               
                 Enterprise Data 
                 EDW 
                 Repository for processed claims. 
               
               
                 Warehouse 
               
               
                 Interactive 
                 IVR 
                 Automated information verification line. 
               
               
                 Voice Response 
               
               
                 Program Benefits 
                 PBA 
                 System for administering program benefits for 
               
               
                 Administration 
                   
                 healthcare benefit companies. 
               
               
                 Provider Cross 
                 PCR 
                 System for administering provider details and 
               
               
                 Reference 
                   
                 relationships. A provider system or network 
               
               
                   
                   
                 may comprise a plurality of TINs that are 
               
               
                   
                   
                 maintained in one or more tables and associated 
               
               
                   
                   
                 with a system generated identifier. 
               
               
                 Health 
                 HIN 
                 System for managing health information 
               
               
                 Information 
                   
                 records and processing EDI transactions. 
               
               
                 Network 
               
               
                   
               
             
          
         
       
     
         [0020]    Claims data as well as non-claims data relevant to the healthcare providers and their business operations is aggregated to facilitate generation of reports for a specified time period. The relevant data may relate to medical claims as well as financials, authorizations, referrals, and customer inquiries. Data from different provider offices or facilities is linked to provide the provider with a comprehensive clinical overview of its claim data. Referring to  FIG. 1A , a daily claims data process according to an example embodiment is shown. In an example embodiment, the process comprises a source phase  100 , a daily incremental phase  102 , and a monthly summary phase  104 . Source feeds  100  include pending claims from the CAS and PBA systems. A data transformation component receives files (e.g., ASCII flat files) through an electronic transfer component. In the daily incremental phase  102 , files are uploaded to a data transformation component. The data transformation component reads the file and loads it into one or more stage tables. From stage tables, daily detail tables are populated. Fifteen months of detail transactions may be stored in daily detail tables for reconciliation purposes. A daily summarization operation is performed and daily summary tables are populated to make monthly summarization more efficient. Monthly summarization is a snapshot of data per reporting month. To facilitate report generation, data may held in a monthly summarization table for 15 months. After 15 months, a month&#39;s data is purged from the table. In stage data may be purged as defined below: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 2 
               
               
                   
               
               
                 Data Purges 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Daily Stage 
                 Daily after successful completion of data load of 
               
               
                   
                 external feeds. 
               
               
                 Daily Summary 
                 At the end of the month and monthly snapshot is 
               
               
                   
                 over with the success flag. 
               
               
                   
               
             
          
         
       
     
         [0021]    In an example embodiment, reports may be generated in the monthly summary phase  104 . A summary table may comprise 15 months of rolling data. Reports may alternatively be generated each calendar quarter and include data relevant for that quarter. 
         [0022]    Referring to  FIG. 1B , a daily non-claims data process according to an example embodiment is shown. In an example embodiment, the process comprises a source phase  106 , a daily incremental phase  108 , and a monthly summary phase  110 . Alternatively, the summary phase may occur quarterly. Source feeds  106  include cross-reference data from the PCR system, IVR transaction data, and HIN system transactions and registrations. A data transformation component receives files (e.g., ASCII flat files) through an electronic transfer component. In the daily incremental phase  108 , files are uploaded to a data transformation component. The data transformation component reads the file and loads it into one or more stage tables and weblog tables. From stage tables, daily detail tables are populated. Fifteen months of detail transactions may be stored in daily detail tables for reconciliation purposes. A daily summarization operation is performed and daily summary tables are populated to make monthly summarization more efficient. Monthly summarization is a snapshot of data per reporting month. To facilitate report generation, data may held in a monthly summarization table for 15 months. After 15 months, a month&#39;s data is purged from the table. In stage data may be purged as defined below: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 3 
               
               
                   
               
               
                 Data Purges 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Daily Stage 
                 Daily after successful completion of data load of 
               
               
                   
                 external feeds. 
               
               
                 Daily Summary 
                 At the end of the month and monthly snapshot is 
               
               
                   
                 over with the success flag. 
               
               
                   
               
             
          
         
       
     
         [0023]    Reports are generated in the monthly summary phase  110 . A summary table may comprise 15 months of rolling data. A PCR hierarchy table also comprises 15 months of data. 
         [0024]    Referring to  FIG. 2A , a sample taxpayer identification number (TIN) document type page according to an example embodiment is shown. A computer user may select a document type of summary by TIN option  120  and then enter a TIN  122  to identify a provider. Referring to  FIG. 2B , a sample name document type page according to an example embodiment is shown. A computer user may select a document type of summary by name option  124  and then enter the name of a provider  126 . 
         [0025]    Referring to  FIG. 2C , a sample summary by name report list page according to an example embodiment is shown. The page comprises a table  128  with the information identified in Table 4. 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 4 
               
               
                   
               
               
                 Report List 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Action 
                 Link to summary report 
               
               
                 Provider Name 
                 Entities associated with provider name or TIN 
               
               
                   
                 specified by user 
               
               
                 Document 
                 For individual provider, TIN 
               
               
                 Identifier 
                 For provider system or network, system generated 
               
               
                   
                 identifier 
               
               
                 Type 
                 S—system 
               
               
                   
                 P—individual provider 
               
               
                 Begin Date 
                 Starting date for report 
               
               
                 End Date 
                 Ending date for report 
               
               
                   
               
             
          
         
       
     
         [0026]    Referring to  FIG. 3A , a sample claims summary report page according to an example embodiment is shown. The page comprises identifying information for the specified entity  130  and a claims summary section  132  that provides a plurality of metrics related to the provider&#39;s volume and dollar amounts. In an example embodiment, the claims volume and dollar metrics comprise: quarterly claims count; quarterly allowed dollars; quarterly paid as percent of allowed; and non-participating claim volume. Data for a current quarter, a prior quarter, the same quarter in the prior year and a 12-month view may be presented. The claims summary report page further comprises a graphical indicator of the healthcare benefit&#39;s company cycle time for claims. Metric definitions for the page are provided in Table 5. 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 5 
               
               
                   
               
               
                 Claims Summary - Volume and Dollars 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Claims 
                 Total number of adjudicated claims, paid or denied, 
               
               
                 Count 
                 during the period. Excludes any currently pended 
               
               
                   
                 claims and those that have not been finalized. 
               
               
                   
                 Represents the total complete claims (not individual 
               
               
                   
                 line items on a claim). 
               
               
                 Allowed 
                 Dollars allowed (includes member responsibility) 
               
               
                 Dollars 
                 during the period. Excludes claims dollars processed 
               
               
                   
                 as out-of-network and dollars paid direct to patient. 
               
               
                 Dollars 
                 Actual dollars paid from the healthcare benefits 
               
               
                 Paid 
                 company during the period. Excludes claims dollars 
               
               
                   
                 processed as out-of-network and dollars paid direct to 
               
               
                   
                 patient. 
               
               
                 Paid as 
                 Percent of dollars paid by healthcare benefits 
               
               
                 Percent 
                 company out of allowed dollars. 
               
               
                 of Allowed 
               
               
                 Non- 
                 Count of claims processed as out-of-network. 
               
               
                 participating 
               
               
                 Claim Volume 
               
               
                 Cycle Times 
                 Timeliness of the healthcare benefits company&#39;s 
               
               
                   
                 adjudication of originally submitted claims (not 
               
               
                   
                 including reprocessed claims). The determination 
               
               
                   
                 is the difference between the receipt date and the 
               
               
                   
                 check date or for denied claims, process date. 
               
               
                   
                 Percentage of all claims and volume of claims 
               
               
                   
                 processed within seven, 14, 21, or over 21 days. 
               
               
                   
               
             
          
         
       
     
         [0027]    Referring to  FIG. 3B , a sample claims details report page according to an example embodiment is shown. A claims details section  136  comprises a plurality of metrics related to the provider&#39;s submission and processing of claims. In an example embodiment the claims submission and processing metrics comprise: electronically submitted claim rate; initially accepted (clean) claim submission rate; paid within 21 days rate; auto-adjudication rate; rate in which contract provisions are not automated; and return to provider rate (denial rate). A “top reasons for pended claims” section  138  presents a graphical indicator of the number of claims that are pended and related reason codes (e.g., duplicate charge or financial recovery). The section further comprises a tip to the provider that may help the provider process claims more quickly. The tip may be based on a certain threshold that a certain metric reaches. The tip, which displays dynamically based on the specific provider&#39;s metrics, serves as an alert to a provider on a key metric and may further indicate an opportunity for the provider to improve and reduce processing delays such as days in accounts receivable. Another section identifies “top reasons for claims return”  140  and presents a tip to assist the provider in reducing claims returns. Metric definitions for the page are provided in Table 6. 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 6 
               
               
                   
               
               
                 Claims Detail Submissions and Processing 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Electronically 
                 Percentage of all claims submitted electronically 
               
               
                 Submitted Claim 
                 and processed during the period excluding any claims 
               
               
                 Rate 
                 rejected by clearinghouses or that did not reach 
               
               
                   
                 the healthcare benefits company claims processing 
               
               
                   
                 system through electronic means. 
               
               
                 Clean Claim 
                 Percentage of claims containing all required 
               
               
                 Submission 
                 data elements per regulatory and/or industry 
               
               
                 Rate 
                 guidelines that did not pend for reasons such 
               
               
                   
                 as coordination of benefits, pre-existing, 
               
               
                   
                 or subrogation. 
               
               
                 Paid within 
                 Percentage of originally submitted claims 
               
               
                 21 Days 
                 processed within 21 days. 
               
               
                 Auto- 
                 Percentage of claims adjudicated without manual 
               
               
                 adjudication 
                 intervention through the healthcare benefit 
               
               
                 Rate 
                 company&#39;s claims processing system. 
               
               
                 Pend Reasons 
                 Top reasons that claim lines did not auto-adjudicate 
               
               
                   
                 and percent each is of total pended lines (specific 
               
               
                   
                 reasons that may display on remit notices are 
               
               
                   
                 grouped by similar types of reasons on the report). 
               
               
                 Rate in which 
                 Percentage of claims in which the allowed amount 
               
               
                 Contract 
                 was manually calculated. 
               
               
                 Provisions are 
               
               
                 Not Automated 
               
               
                 Return to 
                 Percentage of claims adjudicated and completely 
               
               
                 Provider Rate 
                 denied; does not include claims in which certain 
               
               
                   
                 lines are denied and other lines are paid. 
               
               
                 Return to 
                 Top reasons for claim denials (specific reasons 
               
               
                 Provider 
                 that may display on remit notices are grouped 
               
               
                 Reasons 
                 by similar types of reasons on this report). 
               
               
                   
               
             
          
         
       
     
         [0028]    To facilitate report generation, pend and denial reasons may be maintained in a table in which similar codes and descriptions are associated. The use of a table obviates the need to display exact and lengthy HIPAA-compliant reason codes. Referring to  FIG. 3C , a sample reprocessed claims report page according to an example embodiment is shown. In an example embodiment the page comprises a reprocessed rate  142  that indicates the percentage of claims that are reprocessed after initial adjudication. The page further comprises a financial recovery section  144  that indicates the provider&#39;s financial recovery for the quarter (amount collected during the quarter and balance due at the end for the quarter). Metric definitions for the page are provided in Tables 7A and 7B. 
         [0000]    
       
         
               
             
               
               
               
             
           
               
                 TABLE 7A 
               
               
                   
               
               
                 Reprocessed Claims - Reprocessing 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 Reprocessed Rate 
                 Percentage of claims reprocessed after initial 
               
               
                   
                   
                 adjudication. Each reprocessing of 
               
               
                   
                   
                 the same claim is included in the rate. 
               
               
                   
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 7B 
               
               
                   
               
               
                 Reprocessed Claims - Financial Recovery 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Setups 
                 Dollar amount of claims identified as potential 
               
               
                   
                 overpayments during the period. 
               
               
                 Collected 
                 Dollar amount healthcare benefits company 
               
               
                   
                 collected during the period. 
               
               
                 Accounts 
                 Cumulative balance owed at the end of the report 
               
               
                 Receivable (AR) 
                 period (point in time). 
               
               
                 Balance 
               
               
                 Top FR Reasons 
                 Top reasons for overpayment setups. 
               
               
                   
               
             
          
         
       
     
         [0029]    Referring to  FIG. 3D , a sample inquiries report page according to an example embodiment is shown. An inquiries section  146  comprises a plurality of metrics related to the provider&#39;s inquires to the healthcare benefit company. The rows of the table indicate the computerized method of the inquiry (e.g., web transactions; IVR cases; calls with representatives; and mail) and the columns of the table indicate the category of inquiry (e.g., benefits and eligibility; claims status; referral and authorization inquiry; and other). A second section of the page  148  indicates the open cases in each category as of the end of the quarter or other reporting period and the percentage of cases closed within 48 hours. The details presented on the page assist the provider in understanding its usage of self-service options as compared to calls and mail. Metrics for the page are provided in Table 8. 
         [0000]    
       
         
               
             
               
               
               
             
           
               
                 TABLE 8 
               
               
                   
               
               
                 Inquiries 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 Open Cases 
                 Number of unresolved inquiries submitted by 
               
               
                   
                 in Each 
                 phone or correspondence as of the last day of 
               
               
                   
                 Category 
                 the reporting period. 
               
               
                   
                 Percent 
                 Percentage of all inquiries submitted by phone 
               
               
                   
                 Closed within 
                 or correspondence resolved within 48 hours 
               
               
                   
                 48 hours 
                 of receipt. 
               
               
                   
                 Percent of 
                 Percentage of inquires for each inquiry method. 
               
               
                   
                 Contact by 
               
               
                   
                 Method 
               
               
                   
                   
               
             
          
         
       
     
         [0030]    Report Timing and Comparisons: In an example embodiment, summaries are available quarterly. Metrics and information (e.g., pends, returns-to-provider, and financial recovery reasons) reflect the specific quarter&#39;s experience for the provider. Quarterly metrics may be compared against the same quarter of the prior year, the prior quarter, and/or the 12 months ending with the quarter for the specific reporting period. 
         [0031]    Report Benchmarks: Benchmarks for detail metrics relate to the healthcare benefits company&#39;s averages for hospital providers and professional providers and represent averages for the specific quarter&#39;s reporting period. 
         [0032]    The disclosed automated system and method allows a computer user to generate and analyze claims metrics for numerous providers, including providers that are part of a network, through the selection of provider identifying data and report type. The ability to generate and analyze claims metrics facilitates process improvements by the provider and the opportunity to reduce administrative overhead and costs. 
         [0033]    While certain embodiments of the present invention are described in detail above, the scope of the invention is not to be considered limited by such disclosure, and modifications are possible without departing from the spirit of the invention as evidenced by the claims: