SYSTEMS AND METHODS FOR RANKING AND SELECTING ELIGIBILITY VENDORS

In various embodiments, a computer-based method may comprise: compiling, by a vendor ranking computer, eligibility rules and vendor statistics regarding vendor eligibility performance; receiving, by the computer, an eligibility request comprising eligibility parameters; querying, by the computer and based upon the eligibility parameters, a vendor database to determine a subset of eligibility vendors; analyzing, by the computer and based upon at least one of the eligibility rules and the vendor statistics, the subset of eligibility vendors; ranking, by the computer and based upon the analyzing, each vendor in the subset of vendors to produce a ranked vendor list; and providing, by the computer, the ranked vendor list to an eligibility system.

DETAILED DESCRIPTION

The systems and methods provide an improved, automated and intelligent eligibility system (“IES”) for determining and ranking of eligibility vendors while optimizing cost, speed, accuracy, completeness and consistency. “Entity” may include any software, hardware, system, individual, provider, payer, consumer, customer, group, business, organization, government entity, and/or any other entity. An “eligibility vendor” may include any entity that facilitates the determination of eligibility and/or coverage based upon an eligibility request.

Various embodiments of IES may be implemented by a system, computer readable medium, internet based system, a method or any combination thereof The systems and methods include a unique combination of one or more features associated with healthcare systems, eligibility software, eligibility systems, insurance systems, billing systems, and/or accounting systems.

An “account” or “account identifier” as used herein, may include any device, code (e.g., one or more of an authorization/access code, personal identification number (“PIN”), Internet code, other identification code, and/or the like), number, letter, symbol, digital certificate, smart chip, digital signal, analog signal, biometric or other identifier/indicia suitably configured to identify or associate an entity within a system (e.g., IES).

FIG. 1shows an exemplary block diagram illustrating major system components for enabling IES115. System100facilitates interaction between a user105and IES115through, in various embodiments, client110with a network connection to an Internet server125by way of the Internet. In various embodiments, Internet server125employs authentication server130to validate credentials, assign proper permissions, and retrieve preferences information for authorized user's105of IES115.

In various embodiments, IES115interfaces and/or interacts with various interfacing systems such as, for example, provider system160, payer system170and payment system180. Such interfaces may be enabled via an application programming interface (“API”, not show inFIG. 1) or via custom integration, point-to-point interfaces, via a bus, a network or another system.

In various embodiments, Internet server125employs application server145to manage various applications and utilities that are utilized by system100. In various embodiments, application server utilizes APL+Win, JBOSS utilizing SEAM, Richfaces JBPM, and/or other Java libraries (jQuery and Javascript), JAX-WS, Apache POI, and/or Quartz. In various embodiments, Internet server125interacts directly with the various systems and components disclosed herein.

IES115may include any number of computing platforms and databases such as, for example, vendor ranking engine (“VTE”)147, workflow engine148and central data repository (“CDR”)150. Other systems may include, for example, insurance systems, eligibility software and systems, payment systems, accounting systems, financial transaction systems, reporting systems, new accounts systems, management information systems, business information systems, external data sources, proprietary systems and the like. Each of the systems may be interconnected within by a network in via any method and/or device described herein. A middleware server and/or application server145may serve as an intermediary between the various systems to ensure appropriate communications between disparate platforms. A report engine retrieves and/or is provided with data from certain of the various systems in order to generate notices, offers, bills, messages, audit reports, and the like.

The system contemplates uses in association with cloud computing, web services, transaction processing, utility computing, pervasive and individualized computing, security and identity solutions, autonomic computing, commodity computing, mobility and wireless solutions, open source, biometrics, grid computing and/or mesh computing.

User105may include any entity that utilizes system100or IES115functionality. User105may include, for example, a user. In various embodiments, user105may interface with IES115, CDR150or payment system150via any communication protocol, device or method discussed herein or known in the art. For example, user105may interact with IES115by way of a web interface (e.g. a “browser application”), an app or a custom application.

Client110comprises any hardware and/or software suitably configured to facilitate requesting, retrieving, updating, analyzing, entering and/or modifying data. For example, in various embodiments, client110is configured to facilitate input, receipt, presentations, analysis and/or review of information relating to social networking services, value transfer services, etc. Client110includes any device (e.g., personal computer) which communicates (in any manner discussed herein) with system100or IES115via any network discussed herein. Such browser applications comprise Internet browsing software and/or apps installed within a computing unit or system to conduct online transactions and/or communications. These computing units or systems may take the form of a computer or set of computers, although other types of computing units or systems may be used, including laptops, notebooks, hand held computers, set-top boxes, workstations, computer-servers, main frame computers, mini-computers, PC servers, pervasive computers, network sets of computers, and/or the like. Practitioners will appreciate that client110may or may not be in direct contact with IES115. For example, client110may access the services of IES115via provider system160, payer system170, and/or through another server, which may have a direct or indirect connection to Internet server125. Client110may be mobile or may be located in a home or business environment with access to a network. In an embodiment, access is through a network or the Internet through a commercially-available web-browser software package.

As those skilled in the art will appreciate, client110includes an operating system (e.g., Windows NT, 95/98/2000, OS2, UNIX, Linux, Solaris, MacOS, Android, iPhone OS etc.) as well as various conventional support software and drivers typically associated with computers, or computing devices. Client110may include any suitable personal computer, mobile device, phone, smart phone, network computer, workstation, minicomputer, mainframe or the like. Client110can be in a home or business environment with access to a network.

Client110may be independently, separately or collectively suitably coupled to the network via data links which includes, for example, a connection to a wireless service provider or an Internet Service Provider (ISP). ISP connections over the local loop is typically used in connection with standard modem communication, cable modem, Dish networks, ISDN, Digital Subscriber Line (DSL), or various wireless communication methods, see, e.g., Gilbert Held, Understanding Data Communications (1996), which is hereby incorporated by reference. It is noted that the network may be implemented as other types of networks, such as an interactive television (ITV) network.

Client110may include any number of applications, code modules, cookies, and the like to facilitate interaction with the various components of system100as shown, for example inFIG. 1. Such interaction may include for example, input data, complete templates/forms, view reports, validate data, approve data, and the like. In various embodiments, client110may store user105preferences and/or any other information disclosed herein on a hard drive or any other local memory device. Accordingly, client110may retrieve and store consumer information within a memory structure of client110in the form of a browser cookie, for example. In various embodiments, client110retrieves information relating to user105from IES115on establishing a session with Internet server125.

Firewall120, as used herein, may comprise any hardware and/or software suitably configured to protect IES115components from users, other networks and systems. Firewall120may reside in varying configurations including stateful inspection, proxy based and packet filtering among others. Firewall120may be integrated as software within Internet server125, any other IES115components or may reside within another computing device or may take the form of a standalone hardware component. Although depicted as a single firewall inFIG. 1, one skilled in the art will recognize that a firewall or multiple firewalls may be implemented throughout system100and/or IES115to enable system and data security.

Internet server125may include any hardware and/or software suitably configured to facilitate communications between client110and one or more IES115components. Further, Internet server125may be configured to transmit data to client110within markup language documents (e.g., XML, HTML, etc.). As used herein, “data” may include encompassing information such as commands, queries, files, data for storage, and/or the like in digital or any other form. Internet server125may operate as a single entity in a single physical location or as separate computing components located together or in separate physical locations.

Internet server125may provide a suitable web site or other Internet-based graphical user interface which is accessible by consumers. In various embodiments, Internet server125employs RedHat Linux Enterprise 5.x Server and Apache Http server. In various embodiments, the Microsoft Internet Information Server (IIS), Microsoft Transaction Server (MTS), and Microsoft SQL Server, are used in conjunction with the Microsoft operating system, Microsoft NT web server software, a Microsoft SQL Server database system, and a Microsoft Commerce Server. Additionally, components such as Access or Microsoft SQL Server, Oracle, Sybase, Informix MySQL, InterBase, etc., may be used to provide an Active Data Object (ADO) compliant database management system.

In order to control access to components of IES115, Internet server125may invoke authentication server130in response to user105submissions of authentication credentials received at Internet server125from client110. Authentication server130may include any hardware and/or software suitably configured to receive authentication credentials, encrypt and decrypt credentials, authenticate credentials, and grant access rights according to privileges (e.g., pre-defined privileges) attached to the credentials. Authentication server130may grant varying degrees of application and data level access to users based on information stored within a database and/or any other known memory structure.

VRE147comprises hardware and/or software modules that execute processes, access data from CDR150and interact with workflow engine148to enable the functionality of IES115. For example, VRE147may query CDR150to obtain a subset of vendors and associated vendor statistics and eligibility rules and use this information as input into a proprietary eligibility vendor ranking algorithm.

Workflow engine148comprises hardware and/or software modules that implement process definition, tracking and execution. Workflow engine148may comprise one or more software applications, modules or data objects. The software may be any executable code written in any software programming language, such as, for example Java®. For example, workflow engine148reads data from CDR150and instantiates a data object (e.g. a Java Bean®) to store the data for use by software modules or other objects.

CDR150may include any hardware and/or software suitably configured to facilitate storing data relating to, for example, eligibility rules, vendor statistics, historical data, cost data, contract data, vendor information, payer information, and the like.

In various embodiments, the system includes special purpose computers, user interfaces (UIs), software modules, logic and/or workflow engines, numerous databases and computer networks. While the system may contemplate upgrades or reconfigurations of existing processing systems, changes to existing databases and system tools are not necessarily required by the system and method.

While the description references specific technologies, hardware, equipment, system architectures and data management techniques, practitioners will appreciate that this description merely discusses various embodiments and that other devices and/or methods may be implemented without departing from the scope of the disclosure. Thus, the detailed description herein is presented for purposes of illustration only and not of limitation. Similarly, while the description may reference a user interfacing with the system via a personal computer user interface, practitioners will appreciate that other interfaces may include mobile devices, smart phones, tablet computing devices, kiosks and handheld devices such as personal digital assistants.

One skilled in the art will appreciate that system100may employ any number of databases in any number of configurations. Further, any databases discussed herein may be any type of database, such as relational, hierarchical, graphical, object-oriented, and/or other database configurations. Common database products that may be used to implement the databases include DB2 by IBM (White Plains, N.Y.), various database products available from Oracle Corporation (Redwood Shores, Calif.), Microsoft Access or Microsoft SQL Server by Microsoft Corporation (Redmond, Wash.), or any other suitable database product. Moreover, the databases may be organized in any suitable manner, for example, as data tables or lookup tables. Each record may be a single file, a series of files, a linked series of data fields or any other data structure. Association of certain data may be accomplished through any desired data association technique such as those known or practiced in the art. For example, the association may be accomplished either manually or automatically. Automatic association techniques may include, for example, a database search, a database merge, GREP, AGREP, SQL, using a key field in the tables to speed searches, sequential searches through all the tables and files, sorting records in the file according to a known order to simplify lookup, and/or the like. The association step may be accomplished by a database merge function, for example, using a “key field” in pre-selected databases or data sectors.

One skilled in the art will also appreciate that, for security reasons, any databases, systems, devices, servers or other components of system100may consist of any combination thereof at a single location or at multiple locations, wherein each database or system100includes any of various suitable security features, such as firewalls, access codes, encryption, decryption, compression, decompression, and/or the like.

“Cloud” or “Cloud computing” includes a model for enabling convenient, on-demand network access to a shared pool of configurable computing resources (e.g., networks, servers, storage, applications, and services) that can be rapidly provisioned and released with minimal management effort or service provider interaction. Cloud computing may include location-independent computing, whereby shared servers provide resources, software, and data to computers and other devices on demand. For more information regarding cloud computing, see the NIST's (National Institute of Standards and Technology) definition of cloud computing at http://csrc.nist.gov/groups/SNS/cloud-computing/cloud-def-v15.doc (last visited Feb. 4, 2011), which is hereby incorporated by reference in its entirety.

The invention may be described herein in terms of functional block components, screen shots, optional selections and various processing steps. It should be appreciated that such functional blocks may be realized by any number of hardware and/or software components configured to perform the specified functions. For example, system100may employ various integrated circuit components, e.g., memory elements, processing elements, logic elements, look-up tables, and/or the like, which may carry out a variety of functions under the control of one or more microprocessors or other control devices.

Similarly, the software elements of system100may be implemented with any programming or scripting language such as C, C++, Java, COBOL, assembler, PERL, Visual Basic, SQL Stored Procedures, extensible markup language (XML), with the various algorithms being implemented with any combination of data structures, objects, processes, routines or other programming elements. Software elements (e.g., modules, engines, etc.) may be implemented as a web service. In various embodiments, web services are implemented using Webservice Interoperability Organization Basic Profile 1.1.

Further, it should be noted that system100may employ any number of conventional techniques for data transmission, signaling, data processing, network control, and/or the like. Still further, system100could be used to detect or prevent security issues with a client-side scripting language, such as JavaScript, VBScript or the like. For a basic introduction of cryptography and network security, see any of the following references: (1) “Applied Cryptography: Protocols, Algorithms, And Source Code In C,” by Bruce Schneier, published by John Wiley & Sons (second edition, 1995); (2) “Java Cryptography” by Jonathan Knudson, published by O′Reilly & Associates (1998); (3) “Cryptography & Network Security: Principles & Practice” by William Stallings, published by Prentice Hall; all of which are hereby incorporated by reference.

Practitioners will appreciate that there are a number of methods for displaying data within a browser-based document. Data may be represented as standard text or within a fixed list, scrollable list, drop-down list, editable text field, fixed text field, pop-up window, and/or the like. Likewise, there are a number of methods available for modifying data in a web page such as, for example, free text entry using a keyboard, selection of menu items, check boxes, option boxes, and/or the like.

System100combines unique app, integration, data analysis and vendor ranking algorithms to enable eligibility vendor ranking and eligibility determination. While certain embodiments of the present invention are disclosed herein in terms of medical insurance eligibility, practitioners will appreciate that the teachings of the present invention may be equally applicable interchangeably between any type of insurance service or application.

Referring again toFIG. 1, in various embodiments, in response to user105accessing IES115(e.g., by logging onto an application or app), Internet server125may invoke an application server145. Application server145invokes logic in VRE147by passing parameters relating to the user's105requests for data. IES115manages requests for data from VRE147and communicates with system101components. Transmissions between user105and Internet server125may pass through a firewall120to help ensure the integrity of IES115components. Practitioners will appreciate that the invention may incorporate any number of security schemes or none at all. In various embodiments, Internet server125receives requests from client110and interacts with various other system100components to perform tasks related to requests from client110.

Internet server125may invoke an authentication server130to verify the identity of user105and assign roles, access rights and/or permissions to user105. In order to control access to the application server145or any other component of IES115, Internet server125may invoke an authentication server130in response to user105submissions of authentication credentials received at Internet server125. In response to a request to access system100being received from Internet server125, Internet server125determines if authentication is required and transmits a prompt to client110. User105enters authentication data at client110, which transmits the authentication data to Internet server125. Internet server125passes the authentication data to authentication server which queries the user database140for corresponding credentials. When user105is authenticated, user105may access various applications and their corresponding data sources.

As discussed herein, responses provided by an eligibility vendor may vary on a payer by payer basis, vendor by vendor basis, and/or call (i.e. query) by call basis. Because of this, choosing any one particular eligibility vendor limits the probability of a successful or accurate eligibility request. IES115ranks multiple eligibility providers and enables the return of the most accurate information available.

In various embodiments, IES115enables an eligibility determination by ranking eligibility vendors and invoking (e.g. querying) a ranked eligibility vendor to determine insurance eligibility and/or estimated payment amounts. For example, a doctor's office (provider) may wish to determine whether a patient that is coming in for an appointment is currently covered by insurance (“status” or “insurance status”) and, if so, whether and in what amounts the insurance covers the services (“coverage”) that are anticipated to be performed by at the appointment. Determining such information is vital to a provider's financial management since many patients either do not have the ability or lack the will to pay significant out of pocket expenses.

The doctor's office wishes to query the patient's insurance company (i.e. the payor) to verify insurance status and coverage. However, as discussed herein, eligibility vendors do not provide access to all insurers. Thus, in various embodiments, the doctor's office accesses IES115(e.g., via an API) to perform the eligibility query. IES115is configured to optimize the search in order to minimize the cost and response time of the search and to maximize the quality of the search results.

With reference now toFIG. 2, in various embodiments, IES115obtains eligibility rules and vendor statistics regarding vendor eligibility performance (Step205). For example, IES115may compile vendor statistics based upon historical eligibility vendor queries and associated results. In various embodiments, with brief reference now toFIG. 3, such statistics may include, data completeness, data accuracy, data consistency, cost, response time, response delivery mechanism, and contract data. Data consistency may refer the consistency of results from a particular vendor given a set of input. For example, some vendors may provide inconsistent coverage results at different times of the day for the same query. In various embodiments, an eligibility vendor may charge different contract rates to conduct a query to the system based upon, for example, time of day or overall volume. For example, an eligibility vendor with a relatively high rate for a low volume of transactions may charge a much lower rate if the volume exceeds a threshold (e.g., such that a new contract rate is activated). Such tiered pricing contract data may be stored in CDR150and utilized by VRE147when ranking vendor costs; for example, it may be cheaper in the long run to use a high priced vendor if historical data shows that the query volume may reach a threshold for which much lower rates (and, thus, a lower average transaction cost) may be achieved.

In various embodiments, IES115may obtain eligibility rules and other parameters from CDR150. For example, CDR150may be configured to store, and may be loaded with, a mapping of eligibility vendors and the providers that each supplies access to. As discussed previously, in the medical industry there may be hundreds of thousands of providers and no single eligibility vendor provides access to all providers. In various embodiments, IES115may access one or more external systems in order to determine which eligibility vendors provide access to which providers.

IES115receives an eligibility request from provider system160(Step210). In various embodiments, the eligibility request may be received via an API, via a stand-alone client110not directly connected to provider system160, and/or via a batch input file interface. The eligibility request includes eligibility parameters such as, for example, name of the insured, date of birth, employer information, date of employment, address information, sex, provider information, date of service, service code(s), payer (e.g. insurer) name, primary insurer, secondary insurer, etc.

IES115queries, based upon the eligibility parameters, a vendor database to determine a subset of eligibility vendors (Step215). In various embodiments, IES115may not produce a subset vendor list and VRE147may apply the ranking algorithm to all of the eligibility vendors. In various embodiments, CDR150may include the vendor database. In various embodiments, querying the vendor database may include querying to determine which eligibility vendors provide eligibility access to the payor identified in the eligibility parameters.

VRE147applies the proprietary ranking algorithm to the subset of eligibility vendors (Step220). In various embodiments, VRE147may access the eligibility rules and/or the vendor statistics in applying the ranking algorithm. For example, VRE147may access data regarding what result delivery mechanism is supported by the eligibility vendors. Such delivery mechanisms may include a file, screen scrape, web service, mail, I-frame, email, text message, etc. In various embodiments, the delivery mechanism supported by the eligibility vendor is a factor indicating the timeliness with which vendor eligibility requests may be provided. In various embodiments, VRE147accesses historical data completeness information that indicates the amount (e.g. number of data elements) received versus the amount requested from various eligibility vendors. In various embodiments, the algorithm may provide a single score for each eligibility vendor or may produce a score for each of several factors (e.g., cost, timeliness, accuracy).

VRE147creates a ranked list of eligibility vendors (Step225) and provides the ranked vendor list to VES115(Step230). In various embodiments, VES115system analyzes the ranked vendor list and queries one or more of the eligibility vendors to obtain eligibility results. The eligibility results may include, for example, insurance status, co-pay information, claim information (e.g. service codes), estimated payment information from payor, estimated out-of-pocket amount for insured, etc.

Benefits, other advantages, and solutions to problems have been described herein with regard to specific embodiments. However, the benefits, advantages, solutions to problems, and any elements that may cause any benefit, advantage, or solution to occur or become more pronounced are not to be construed as critical, required, or essential features or elements of the invention. The scope of the invention is accordingly to be limited by nothing other than the appended claims, in which reference to an element in the singular is not intended to mean “one and only one” unless explicitly so stated, but rather “one or more.” Moreover, where a phrase similar to ‘at least one of A, B, or C’ is used in the claims or specification, it is intended that the phrase be interpreted to mean that A alone may be present in various embodiments, B alone may be present in various embodiments, C alone may be present in various embodiments, or that any combination of the elements A, B and C may be present in a single embodiment; for example, A and B, A and C, B and C, or A and B and C. All structural, chemical, and functional equivalents to the elements of the above-described exemplary embodiments that are known to those of ordinary skill in the art are expressly incorporated herein by reference and are intended to be encompassed by the present claims. Further, a list of elements does not include only those elements but may include other elements not expressly listed or inherent to such process, method, article, or apparatus.