Abstract:
A system and related techniques capture and regulate the stream of billing items generated in a hospital or other clinical facility for compliance with federal Medicare or other regulatory or other guidelines. In embodiments a conditioning engine may apply rules-based logic or other filters to raw billing information derived from clinical tests, procedures, prescriptions or other patient encounters or care. That raw billing information may be examined for compliance with current regulatory or other guidelines against a compliance database or template, to determine for example whether clinical lab or test records, charts or other necessary documentation exists to support a billed item and satisfy reimbursement guidelines. Billing items whose supporting documentation does not exist or requires further exploration may be conveyed to a holds queue, to hold the billing on those items until documentation may be resolved. Administrators and others may then examine held items for release and bill drop. Because billing items are conditioned to satisfy Medicare or other standards prior to transmission of a bill or invoice, compliance may be assured or significantly enhanced as compared to prior industry practices such as retroactive audits for Medicare compliance.

Description:
CROSS-REFERENCE TO RELATED APPLICATION  
       [0001]     Not applicable.  
       STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT  
       [0002]     Not applicable.  
       FIELD OF THE INVENTION  
       [0003]     The invention relates to the field of management information systems, and more particularly to an integrated platform to capture and condition individual patient charges to ensure compliance with regulatory and/or administrative documentary guidelines.  
       BACKGROUND OF THE INVENTION  
       [0004]     As the proportion of medical billing satisfied under the federal Medicare and state indigent care (Medicaid) programs increases, the importance of confirming the existence of required documentation used to affirm and support clinical billing practices has grown greater. The Centers for Medicare and Medicaid Services (CMS) mandate a range of charge-level, documentation/affirming data elements that support the appropriate reimbursement of claims by hospitals, physicians and other clinical sites. A broad principle underlying the requirements is that reimbursed care be driven and delivered on a basis of medical necessity. The CMS and other regulations among other things prescribe that adequate clinical documentation and/or affirming data elements exist for delivery of medicines, procedures and other care undertaken for a patient, in part to help establish that medical necessity.  
         [0005]     However, many hospitals and other clinical sites do not regularly or comprehensively generate all supporting documentation or affirming data elements required by CMS and other regulatory bodies. This prevailing industry behavior may in part be a result of the fact that existing medical information infrastructure does not or cannot track, generate and associate needed patient documentation to connect that documentation to individual patient charges that are submitted to CMS intermediaries for payment. Certain commercially available tools exist which examine or “scrub” claim forms for internal consistency, for example to ensure erroneous or duplicate codes are not entered. However such packages do not attempt to verify the existence of independent clinical documentation or affirming data elements needed to support the bill or claim, before generating or finalizing the billing item.  
         [0006]     Lacking effective or integrated tools, some organizations may therefore rely upon periodic manual audits or samples of patient billing, to retroactively examine compliance with Medicare or other billing guidelines. However, that type of program review merely permits administrators to spot deficiencies in documentation practices after the fact, a shortcoming that is only heightened by the possibility of compliance audits by the department of Health and Human Services (HHS) or other entities.  
       SUMMARY OF THE INVENTION  
       [0007]     The invention overcoming these and other problems in the art relates in one regard to a system and method for automatic conditioning of individual patient charges, in which charges arising from clinical care are captured and processed in an integrated platform to enforce compliance with Medicare, Medicaid or other regulatory or other documentation/affirming data element requirements. In embodiments, a conditioning engine may receive the raw clinical and billing data and check that data against a compliance documentation/affirming data element template to determine whether necessary support for the item being billed exists. When documentation or support does exist, the billing item may be communicated to further billing platforms to release the bill for subsequent evaluation or to the patient, insurance company or other payor or other entity. Billing items for which documentation/affirming data elements may not be verified or immediately verified may be communicated to a holds queue, from which further or more extensive compliance checking may be carried out. Billing items which may be verified out of the holds queue may be likewise be transmitted in normal course, while items whose documentation cannot be verified may be suspended pending account review or other action. In embodiments the level of desired support to qualify a billing item or other details of that billing event or its compliance may be selected by a billing administrator or otherwise. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0008]      FIG. 1  illustrates an architecture in which a system and techniques for automatic conditioning of clinically related billing may operate, according to embodiments of the invention.  
         [0009]      FIG. 2  illustrates a compliance template, according to embodiments of the invention.  
         [0010]      FIG. 3  illustrates a configuration profile managed by a configuration module, according to embodiments of the invention.  
         [0011]      FIG. 4  illustrates overall billing processing, according to an embodiment of the invention. 
     
    
     DETAILED DESCRIPTION OF EMBODIMENTS  
       [0012]      FIG. 1  illustrates an architecture in which a system and method for automatic conditioning of clinically related billing may operate, according to an embodiment of the invention. As illustrated in that figure, in embodiments a clinical event  102  such as an examination, evaluation, surgery or other patient encounter or care may take place, for instance in a hospital, clinic or other site. Details of the clinical event  102  may be captured during or after the delivery of that care or attention and be transmitted to a clinical data store  104 , which may be or include for example a database or other data store. The details of the clinical event  102  may include, for example, patient identifying information, insurance account or other information, patient charts, physicians orders, procedure codes, outcomes or other data associated with the clinical attention the patient receives or is scheduled to receive.  
         [0013]     In embodiments, the clinical data store  104  may communicate with a billing capture engine  106  to enter and extract billable or potentially billable items or data related thereto, such as pharmaceutical prescriptions, patient supplies, physician services, anesthesiology or radiology services, or other medication, material, supplies or services. Billing capture engine  106  may generate a preliminary billing item  116  as a result of initial data capture and parsing, which item may be or include procedure codes, physician identification, insurance or other coverage data, date or dates of medical encounters or care, or other information supporting or related to the billing of services or materials related to clinical event  102 .  
         [0014]     According to embodiments of the invention, the preliminary billing item  116  may be transmitted to a conditioning engine  108  to develop and qualify the preliminary billing item  116  under mandatory billing guidelines or other requirements. According to embodiments of the invention in one regard, the conditioning engine  108  may analyze and condition the finalization of preliminary billing item  116  upon compliance with Medicare, Medicaid or other regulatory or other requirements, to ensure that the resulting bill is compliant and payable in the form transmitted. More particularly, upon receipt of preliminary billing item  116 , conditioning engine  108  may access a compliance database  112  to compare the recorded procedure codes, medication administration record (MAR), physicians orders or other supporting information related to preliminary billing item  116  to the necessary criteria for Medicare, Medicaid or other public or private entities to accept and pay for that billing item.  
         [0015]     According to the invention in one regard, the clinically related billing contained in preliminary billing item  116  or other billing related objects may therefore be prospectively predicated on compliance with those requirements. The chances of generating or transmitting an inadequately supported or noncompliant bill, for example due to lack of demonstrated clinical necessity or on other grounds, may therefore be eliminated or significantly reduced. Collections on transmitted billing items and institutional compliance status may therefore be improved.  
         [0016]     More particularly and as further illustrated in  FIG. 1 , the conditioning engine  108  may access compliance database  112  and interrogate a compliance template  122  to determine necessary criteria to qualify preliminary billing item  116  under Medicare, Medicaid or other regulations or rules. The compliance template  122 , an illustration of which for cardiac related care is shown in  FIG. 2 , may include data fields for necessary codes, charts, records and other information needed to satisfy those criteria, including, as illustrated, verification of physician referrals, physicians orders, diagnosis and date of onset, diagnostic code, history and physical records, and other data or reports. According to the invention in one regard, and returning to  FIG. 1  as illustrated in that figure, the selection and application of data fields or other variables used or applied in compliance template  122  may in embodiments be configured by a billing administrator or others using configuration module  114 , for instance using a computer workstation or other client or interface.  
         [0017]     That is, different levels of internal, external or other documentation or affirming data elements necessary to support and satisfy the conditions recorded in compliance template  122  may be adjusted or configured. For instance and as illustrated in  FIG. 3 , the compliance template may be configured or adjusted in a configuration profile  124  to require that a treatment plan, physicians order or other documentation or information be verified to exist, but affirming data elements in that plan order not be produced, as opposed to the verification of the plan or order and the verification or extraction of all affirming data elements that may be populating that plan or order. Other data fields or status indicators, such as a flag or other field indicating that a report or other documentation or support is pending, may be selected for acceptance depending on implementation or administrative circumstances, such as the availability of other or cooperating data stores or interfaces in the overall management information system. As used herein, “documentation” may refer broadly to any hard copy, electronic, optical or other report, data, file or other media or content, in textual, numeric or other format, which temporarily or permanently reflects or records information related to the delivery of clinical care.  
         [0018]     In embodiments the compliance database  112  or one or more compliance templates  122  hosted in compliance database  112  may be generated by government entities such as Medicare, Medicaid, CMS or other entities or bodies, be generated by private companies or others based on public regulatory guidelines or other requirements, or by combinations of those sources for mandatory or other billing guidelines. In embodiments, the compliance database  112  may be accessed by billing administrators or others on a subscription or non-subscription basis, and may in embodiments be updated or extensible according to changing regulations and other conditions.  
         [0019]     In embodiments and as shown in  FIG. 1 , when conditioning engine  108  generates a comparison or analysis of the preliminary billing item  116  against compliance database  112  including any one or more compliance templates  122  which may be selected or used, if the preliminary billing item  116  does not reflect or incorporate or does not fully reflect or incorporate records sufficient to satisfy Medicare, Medicaid or other guidelines, in embodiments an exception may be generated. In that instance the conditioning engine  108  may transmit or convey the preliminary billing item  116  or data related thereto (such as, for example, data fields lacking documentation) to a holds queue  110 . The holds queue  110  may be or include local or remote temporary or other storage to receive those billing items or constituent data of those items for which compliance may not be verified, or immediately verified. This may occur for example because a record of physician progress notes terminates at a date too early in the care cycle, a procedure code is missing, incomplete or inconsistent, or for other reasons or grounds. In embodiments, the conditioning engine  108  may apply rules-based logic to determine or assess the completeness or adequacy of a given data field or other information, for instance to locate redundant entries, translate codes from old schemes to new, or perform other logic or tests against the preliminary billing item  116  and its populated data.  
         [0020]     The one or more preliminary billing item  116  or related data placed in holds queue  110  may be subjected to further processing and review to validate the documentation and/or affirming data elements for the materials or services to be billed. In embodiments for example, the conditioning engine  108  may automatically communicate with additional, independent, ancillary or other clinical or other data stores to supplement the clinical notations in preliminary billing item  116 . Other records or databases, such as insurance, patient supply record, or other data stores may likewise be accessed, for instance to scan for updated or changed patient account numbers, correlate changed or inaccurately recorded patient names, or otherwise extend the survey or search for supporting documentation or affirming data elements for the preliminary billing item  116 . In further embodiments, the exceptions trapped in holds queue  110  may be manually or partly manually reviewed by a billing administrator or other user to similarly inspect the clinical data and other sources to satisfy the compliance template  122  or other criteria.  
         [0021]     When the evidentiary support for a preliminary billing item  116  residing in holds queue  110  has been satisfactorily verified or supplied, again in embodiments to levels which may be configured in configuration profile  124 , the preliminary billing item  116  or related data may be released from holds queue  110  and returned to conditioning engine  108  for release to outbound billing or other processing. In embodiments as shown in  FIG. 1 , the conditioning engine  108  may therefore generate a verified billing item  120  for transmission to a billing platform  118 , which may be or include an internal or external accounts receivable, tracking or other package or platform. In embodiments the verified billing item  120  may include electronic attachments or other annotations of some or all of the supporting documentation used to verify compliance with compliance template  122 . In embodiments pointers or links to some or all of that supporting documentation may also be embedded in verified billing item  120 , separately or in combination with direct attachments. In cases where further review of exceptions trapped in holds queue  110  does not resolve open compliance issues, in embodiments the preliminary billing item  116  or related data may be removed from holds queue  110 , for example to be transferred to a billing administrator for case-by-case recovery review.  
         [0022]      FIG. 4  illustrates overall compliance processing, according to embodiments of the invention. In step  402 , processing may begin. In step  404 , details of a clinical encounter or encounters, treatment or care may be captured for a patient, and stored to clinical data store  104  or other database. In step  406 , the clinical treatment details, such as attending physician, procedure code, pharmaceutical codes or other clinical notations or records may be transmitted to billing capture engine  106 . In step  408 , a compliance template  122  may be automatically or manually selected or configured, for example via configuration module  114 . In step  410 , the billing capture engine  106  or other resource may generate a preliminary billing item  116  and transmit that billing record to conditioning engine  108 . In step  412 , the preliminary billing item  116  may be analyzed by comparison against the compliance template  122  or other filters or data points, for example for compliance with required Medicare, Medicaid or other mandated or other documentation/affirming data elements or support.  
         [0023]     In step  414 , any exceptions detected from analysis of the preliminary billing item  116  may be communicated to the holds queue  110 . In embodiments, billing administrators or others may be notified of the exceptions arriving in or populating holds queue  110 , for instance via automated information system workflow, email, voice mail or other messaging or channels. In step  416 , the existence of documentation/affirming data elements or other support or evidence sufficient to qualify the one or more preliminary billing items  116  or data from that item may be searched for. In embodiments, that necessary documentation or other evidentiary support, for example patient charts, physician orders or prescriptions, radiology plans or other documents, images, objects or data may be automatically scanned for by conditioning engine  108  and other resources. In further embodiments, clinical, billing or other administrators may manually or partly manually search databases or other data sources to locate the necessary criteria, for instance by reviewing logs or records from radiology, surgery or other departments associated with or performing the related care.  
         [0024]     In step  418 , the exceptions held in holds queue  110  may be automatically or manually released from that waiting area, when qualifying documentation or other support is confirmed. In step  420 , a resulting verified billing item  120  may be transmitted to a billing platform  118 , for instance a billing or receivables package or tool. In step  422 , any downstream billing processing, such as human spot checks or other verifications or reviews, may be performed and the verified billing item  120  transmitted to the patient, paying party or other recipient, for instance via mail or other channels. In step  424 , processing may repeat, return to a prior processing point or end.  
         [0025]     The foregoing description of the invention is illustrative, and modifications in configuration and implementation will occur to persons skilled in the art. For instance, while the invention has generally been described in terms of a single conditioning engine that captures and processes a clinical billing stream for compliance, in embodiments the rules or logic applied to enforce documentation and other compliance may be distributed among multiple engines or other resources.  
         [0026]     Similarly, while the invention has in embodiments been generally described as examining billing items for compliance with Medicare or Medicaid criteria, the inventive platform may in embodiments apply criteria derived from other federal, state or other commercial, public or private programs. Other hardware, software or other resources described as singular may in embodiments be distributed, and similarly in embodiments resources described as distributed may be combined. The scope of the invention is accordingly intended to be limited only by the following claims.