Patent Publication Number: US-2017351823-A1

Title: Medical payment system

Description:
RELATED APPLICATIONS 
     Any and all applications for which a foreign or domestic priority claim is identified in the Application Data Sheet, or any correction thereto, are hereby incorporated by reference into this application under 37 CFR 1.57. 
     BACKGROUND OF THE INVENTION 
     Field of the Invention 
     The present invention is related to payment systems, and, in particular, to medical payment systems. 
     Description of the Related Art 
     Payment amounts for medical care in the US are increasingly set by Preferred Provider Organizations (PPO&#39;s) that negotiate reduced rates with medical providers for medical services and goods provided to patients. Agreeing to accept the reduced rates offered by a PPO introduces a medical provider to the population of patients that are affiliated with the PPO. Individual medical providers may negotiate contracts with many different PPO&#39;s, each with its own negotiated fee schedule that specifies the contracted payment amount for each medical good and service offered by the provider. 
     Fee schedules are updated when fees change, especially when a negotiated fee is based on another rate, such as an agreed percentage off of standard Medicare rates. Fee schedule updates are typically transmitted to providers as printed pages of updates that can be kept in the provider&#39;s office in binders that may be numerous, unwieldy to handle, and difficult to reference. Attempting to quickly determine which fee schedule is the appropriate one to use for a given patient encounter can be difficult for the provider, especially when the patient belongs to a health plan with access to fee schedules from more than one PPO. 
     Some PPO&#39;s maintain websites that providers can access via computer network in order to get payment amount information based on the PPO&#39;s current fee schedule, but providers have thus far demonstrated reluctance to access payment information or to submit claims for payment via computer. According to one report, only 10% of providers who could use the computer to access payment amount information do so. Several factors may help to explain this fact: lack of available computer equipment at the time of patient check-out, lack of comfort on the part of the provider in using the computer and interacting with the various input requirements and interface styles of the different PPO websites, inability of the PPO website to provide a quick and easy interface to its services, and lack of speed and/or capacity of the provider&#39;s computer connection, amongst other reasons. Furthermore, having access, by paper or by computer, to individual PPO fee schedules does not help the provider determine which PPO fee schedule is appropriate to use for a given patient encounter when the patient&#39;s health plan offers access to more than one PPO fee schedule. 
     SUMMARY OF THE INVENTION 
     A medical payment system is described that allows a medical provider to communicate by telephone, using voice and/or telephone keypad, to submit information about an encounter with a patient and to receive information about an associated payment amount owed to the provider for the medical services and goods provided. In some embodiments, an interactive voice response system (IVRS) allows the provider and the price determination system to communicate in a manner that is convenient and easily understandable for the provider. 
     A medical payment system is described that allows a medical provider to request and to receive payment amount information for an encounter with a patient who belongs to a health plan that comprises one or more negotiated Preferred Provider Organization (PPO) fee schedules. A price determination system locates an appropriate fee schedule for the encounter and calculates a payment amount for medical goods and/or services associated with the patient encounter. For health plans that comprise a plurality of fee schedules, the price determination system accesses information about a hierarchical ranking of the fee schedules. The price determination system selects, from amongst the fee schedules negotiated by the provider, the fee schedule that has the highest ranking in the hierarchy, and uses the selected fee schedule to calculate the payment amount for the patient encounter. 
     In some embodiments, when payment of all or part of the calculated payment amount is the responsibility of at least one party or entity other than the patient, the provider may also use the system to submit a claim to a responsible third party or entity, such as a medical insurance company or third party administrator, a medical credit card account, or other source of funds dedicated for payment of the patient&#39;s medical expenses. In one embodiment, information about the calculated payment amount can be transmitted to a responsible third party or entity so that payment may be transmitted directly to the provider&#39;s bank account. 
     In one embodiment, a healthcare price determination method is described, in which the method comprises: receiving, via telephone, information about at least one patient encounter with a medical provider; determining the contracted payment amount associated with the encounter; and communicating via a voice response system the determined payment amount to at least the medical provider. The price determination method may further comprise transmitting information about the payment amount to a responsible party or entity, so that a claim for payment to the provider may be submitted, and payment may be subsequently transmitted to a bank account associated with the provider. 
     For purposes of summarizing embodiments of the invention, certain aspects, advantages, and novel features of the invention have been described herein. It is to be understood that not necessarily all such aspects, advantages, or novel features will be embodied in any particular embodiment of the invention. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  depicts an overview of one embodiment of a medical payment system that comprises a price determination system. 
         FIG. 2A  depicts one embodiment of an eligibility list used by a price determination system. 
         FIG. 2B  depicts one embodiment of a priority list used by a price determination system. 
         FIG. 2C  depicts one embodiment of a provider list used by a price determination system. 
         FIG. 3  is a flowchart that depicts one embodiment of a medical payment system. 
         FIGS. 4A and 4B  (hereinafter referred to collectively as “ FIG. 4 ”) present a flowchart that depicts one embodiment of an encounter information input system. 
         FIG. 5  is a flowchart that depicts one embodiment of a method to determine a contracted payment amount for a patient encounter. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     A medical payment system is described in which a provider of medical goods and/or services submits, via telephone or other communications medium, a request for payment amount determination for a patient encounter and in which the provider receives via an interactive voice response system (IVRS) information about the requested payment amount. A price determination system determines which of a plurality of fee schedules negotiated by the provider applies to the patient encounter and calculates, based at least in part on information entered by the provider, a payment amount for the encounter, which it communicates to at least the provider. In one embodiment, the provider receives the payment amount information while the patient is at the point of service. In one embodiment, the provider receives information about a first portion of the payment amount, if any, for which it is the patient&#39;s responsibility to pay and a second portion of the payment amount, if any, which is to be paid by another responsible party or entity. In one embodiment, the provider may use the system to submit a claim for payment to at least one responsible party or entity. 
       FIG. 1  depicts an overview of one embodiment of the medical payment system. In brief,  FIG. 1  depicts a system in which a patient  100  goes to a medical provider  110  for medical goods and/or services. An instance in which the patient  100  visits the provider  110  and receives medical goods and/or services can be called a patient encounter. The medical provider  110  communicates by telephone or by other communications method with a price determination system  115  in order to determine the payment amount due to the provider  110  for the encounter. The price determination system  115  calculates a payment amount, as will be described in greater detail below and communicates the amount to the provider  110  and, if applicable, to one or more parties or entities that are responsible for paying the provider  110 . In one embodiment, the price determination system  115  communicates the payment amount back to the provider&#39;s office  110  immediately so that the patient  100  can pay the provider  110  before leaving the provider&#39;s office  110 . In one embodiment, when some or all of the payment amount is to be paid by a third-party payor  190 , such as a medical insurance company, or from a medical credit card account  195 , or is to be paid from a purse  192 , as will be described in greater detail below, the price determination system  115  communicates information about the payment amount to the payor  190 , the purse  192  and/or the medical credit card account  195  so that payment may be made directly to a bank account  112  associated with the medical provider  110 . 
     Describing  FIG. 1  now in more detail, the provider  110  depicted may be a doctor, a pharmacist, a dentist, an optometrist, a hospital, or other medical practitioner or provider of medical goods or services. A representative of the provider  110 , such as a receptionist, billing specialist, or other assistant, may initiate and execute the communication between the provider&#39;s office  110  and the price determination system  115 , and, for purposes of this description, the term “provider” will refer to a provider or other person operating on behalf of the provider in communicating with the price determination system  115 . 
     In one embodiment, the patient  100  presents to the provider  110  a medical plan card  105  that represents the patient&#39;s  100  membership in a group, known for purposes of this application as a client group, that offers a medical plan to its members. In one embodiment, access to the medical plan confers upon the patient  100  eligibility to receive medical care and/or goods at a contracted reduced rate. 
     The client group may provide discounted rates on medical goods and services for their members by building a medical plan from medical pricing contracts available through one or more Preferred Provider Organizations (PPO&#39;s). The PPO&#39;s negotiate pricing contracts with medical providers who agree to accept individually determined reduced payment rates for their goods and services in exchange for access to the patient base offered by the PPO. In one embodiment, the medical providers  110  also agree to accept reduced payment rates in return for a guarantee of immediate or expedited payment for patient encounters. A medical provider  110  typically contracts with a number of PPO&#39;s and may thus have agreed to accept a wide variety of contracted payment rates for each given medical good or service. For the provider  110  to determine the correct contracted rate for the goods and services associated with a given patient encounter is typically a complex and time-consuming task and often cannot be accomplished while the patient  100  is waiting to check out from the provider&#39;s office  110 . Thus, the provider  110  may lose the opportunity to receive payment at the time of service and may have to expend time and money to bill the patient  100  at a later date and to hope to receive payment without enduring a protracted delay. 
     In one embodiment, information on the medical plan card  105  comprises a telephone number that allows the provider  110  to dial and access via telephone an interactive voice response system (IVRS) that is associated with the price determination system  115  and that is configured to accept and to transmit information about a calculated payment amount for the patient encounter, as will be described in greater detail with reference to  FIGS. 3-5  below. In one embodiment, the provider  110  communicates with the price determination system  115  about a calculated payment amount for the patient encounter using a computer that is configured to access a computer network, such as the Internet, to which the price determination system  115  is also connected. In other embodiments, other methods of communication are used that allow the provider  110  to receive payment amount information for a patient encounter, including by way of example, dedicated communication lines, telephone networks, wireless data transmission systems, two-way cable systems, customized computer networks, interactive kiosk networks, automatic teller machine networks, interactive television networks, and the like. 
     One advantage of a telephone-based embodiment is the ease of use and uniformity of availability that it offers to the provider  110 . While computers are becoming increasingly common in provider offices, discrepancies still exist in the capabilities of computer equipment and staff at provider offices. Lack of an available computer at a provider&#39;s check-out desk, lack of reliable computer network connection, slow transmission rates, and inability or unwillingness of office staff to use the computer are all conditions that currently exist. In fact, although computer systems for submitting some types of medical insurance claims for later payment do exist, statistics indicate that only around 10% of provider offices currently choose to make use of such systems. Telephones, on the other hand, are virtually ubiquitous in medical provider offices, and office staff are familiar and comfortable with their operation. 
     The ability on the part of the provider  110  to access payment information, whether by telephone or by other communication method, at the point and time of service represents an improvement over current systems in which the provider  110  typically waits three to six months for payment. In some current systems, the provider  110  submits a paper-based request for payment information to a PPO and must wait for a written response before being able to accurately bill the patient  100 . In some current systems, the provider  110  bills the patient  100  a standard rate that may exceed the contracted PPO rate to which the patient  100  is entitled and that must later be adjusted and refunded. In such systems, even if a patient  100  desires to pay at the point of service, accurate payment amount information may not be readily available. In embodiments where a patient  100  shares responsibility for paying the provider  110  with another party or entity, such as a medical insurance company  190  or a source of funds  192  for payment of the patient&#39;s medical expenses, communicating with the price determination system  115  at the point of service allows the provider  110  to accurately inform the patient  100  of the portion of the total payment amount for which the patient  100  is responsible and to request immediate payment for that portion. 
     In one embodiment, communicating with the price determination system  115  also allows the provider  110  to submit a claim on behalf of the patient  100  to any parties or entities  190 ,  192 ,  195  that are responsible to pay the provider  110  for all or part of the payment amount associated with the patient encounter. 
     As depicted in the embodiment of  FIG. 1 , the price determination system  115  comprises client-specific data  120 , which, when supplemented as needed by price calculation data  125 , allows the price determination system  115  to accurately calculate the contracted payment amount for a patient encounter. In one embodiment, the price determination system  115  operates using computer program logic that may advantageously be implemented as one or more computer modules configured to execute on one or more processors. For the purposes of this description, computer modules may comprise, but are not limited to, any of the following: software or hardware components such as software object-oriented software components, class components and task components, processes methods, functions, attributes, procedures, subroutines, segments of program code, drivers, firmware, microcode, circuitry, data, databases, data structures, tables, arrays, or variables. 
     The client-specific data  120  of the price determination system  115  comprises information specific to the medical plan of the client group to which the patient  100  belongs and instructions about how payment determination is to be carried out for encounters associated with the client group. The price calculation data  125  comprises information that may apply to all or many of the client groups serviced by the price determination system  115  and that may be used for calculating a payment amount for an encounter involving a patient from any of the client groups associated with the price determination system  115 . In one embodiment, client-specific data  120  is implemented as a computer module. 
     In one embodiment, client-specific data  120  for a given client group is indexed or accessed via a client group access number  130 , and dialing the telephone number printed on the patient&#39;s  100  medical plan card  105  automatically connects the provider  110  to the appropriate client group access number  130  for the client group to which the patient  100  belongs. Thus, the price determination system  115  is able to provide payment information for patients  100  from a variety of medical plans using a single, simple, standardized interface and to quickly access the appropriate information in order to calculate an accurate payment amount for the patient encounter. 
       FIG. 1  depicts some examples of the types of client-specific data  120  that may be stored and used by the price determination system  115  in determining the contracted payment amount for an encounter and in submitting a claim for the determined amount to one or more responsible parties. In some embodiments, some or all of the client-specific data  120  are implemented as computer modules, as was described above. 
     An eligibility list  135 , which will be described in greater detail with reference to  FIG. 2A , comprises information about whether a given patient  100  is eligible for some, all, or none of the benefits offered to members of the client group. A provider list  140 , which will be described in greater detail with reference to  FIG. 2B , comprises information about providers who are affiliated with the PPO&#39;s that have contracted with the client group. A priority list  145 , which will be described in greater detail with reference to  FIG. 2C , comprises information about a hierarchy of PPO&#39;s that make up a medical plan and about how to determine the correct contracted rate for a provider who is affiliated with more than one PPO. 
     Fee schedules  150  stored with the client-specific data  120  of a given client group comprise information about how to calculate the payment amount agreed to by a given provider  110  in affiliation with a given PPO. In some embodiments, the fee schedules  150  are implemented as one or more computer modules. In some embodiments, the agreed amounts are fixed and are constant for all providers  110  affiliated with the PPO. In some embodiments, providers are grouped by their zip codes, and providers in a given zip code are paid at the same rate. In some embodiments, the payment amounts are calculated as a percentage off the provider&#39;s  110  usual billed rate for the service or good. In some embodiments, the amounts are calculated using standard Medicare rates as a basis. In some embodiments, rates for certain goods or services are calculated in one way, while rates for other goods or services are calculated in another way. In some embodiments, a PPO may have arrived at different agreements with different affiliated providers for various goods and services, and information describing these agreements is stored within the fee schedule  150  for the PPO. Thus, in some embodiments, the client-specific data  120  for a given client group may comprise a fee schedule  150  for each PPO that forms a part of the client group&#39;s medical plan. 
     Fee schedules are updated periodically, often every four to six weeks, in order to reflect changes in a PPO&#39;s contracted rates. Using the price determination system  115  to easily access current and accurate payment amount information at the point of service rather than attempting to locate the desired information in written format using the numerous and often unwieldy binders provided by individual PPO&#39;s is another advantage offered to the patient  100  and the provider  110  by the price determination system  115 . 
     Client-specific data  120  for a client group also comprises benefit coverage/payment rules  155  that provide instructions to the price determination system  115  regarding how the patient encounter payment amount is to be calculated for the client group&#39;s medical plan and how claims to responsible parties and entities are to be submitted for the client group&#39;s medical plan. In one embodiment, the benefit coverage and payment rules  155  are implemented as one or more computer modules. Benefit coverage/payment rules  155  will be described in greater detail below, still with reference to this figure. 
     As described above, in addition to the client-specific data  120  indexed by client group access number  130 , the price determination system  115  also comprises general purpose price calculation data  125  that may be useful for determining a contracted payment amount for a patient encounter associated with any client group. Some examples of such price calculation data  125  are depicted in  FIG. 1 . 
     Accurately describing the procedures associated with a patient encounter can be accomplished using Current Procedural Terminology (CPT) codes  160  and CPT modifiers  165  that are defined and maintained by the American Medical Association and that are used as an industry standard to describe over seven thousand different procedures. In one embodiment, each CPT code  160  is associated with a multiplier value that is used in conjunction with information from the fee schedule  150  to calculate the contracted payment amount. For example, a fee schedule may indicate that for providers in a given zip code area, all procedures with CPT codes  160  beginning with a “9,” which indicates an office visit procedure, are paid at a rate of $5.40 per multiplier unit. If an extended office visit, with CPT code “90028,” has a multiplier value of 8.2, then a provider  110  in the given area who requests pricing for an extended office visit will be given the PPO-negotiated payment amount of $44.28. In one embodiment, the price calculation data  125  also comprises Health Care Procedure Codes (HCPC), which use a five-digit alphanumeric system to identify coding categories not covered by CPT codes. 
     Other price calculation data  125  that may be stored by the price determination system  115  are ICD-9 codes  170 , which are an industry standard used to describe medical diagnoses, current Medicare rates  175 , which may be used in some situations as the basis for a PPO-negotiated payment amount, and tables of zip codes  180 . Some, all, or none of these types of data, along with other data used by the price determination system  115  to calculate a contracted payment amount for a patient encounter and for apportioning responsibility for paying the payment amount may be stored as general purpose price calculation data  125 . In some embodiments, some or all of the price calculation data  125  is implemented as one or more computer modules. 
     Using information from the client-specific data  120  and any necessary price calculation data  125 , the price determination system  115  is able to calculate the appropriate contracted payment amount for the patient encounter. 
     As was described briefly above, the client-specific data  120  comprises benefit coverage and payment rules  155  that instruct the price determination system  115  on how to calculate the contracted payment amount and, if desired, how to further process the payment amount information for a given client group&#39;s medical plan. In some embodiments, the benefit coverage and payment rules  155  allow the price determination system to accommodate health plans in which responsibility for paying some or all of the contracted payment amount may be shared with the patient  100  by a third-party payor  190 , a medical credit card account  195 , or a medical payment fund  192 . The benefit coverage and payment rules  155  are formulated to suit the needs of the given medical plan and to allow the price determination system  115  to flexibly serve the needs of a wide variety of medical plans. 
     As an example, in one embodiment, a client group&#39;s medical plan may provide access to PPO-negotiated rates for medical goods and services that the patient  100  agrees to pay to the provider  110  in full at the point of service. In this example, the benefit coverage and payment rules  155  may instruct the price determination system  115  to use the client-specific data  120  and the price calculation data  125  to calculate the contracted payment amount and to communicate the amount back to the provider  110  verbally using the IVRS. In some embodiments, options may also be provided to send a written copy of the price determination to the provider  110  via fax transmission and/or to the patient&#39;s home address via postal service. 
     As another example, a client group&#39;s medical plan may provide access to PPO-negotiated rates for medical goods and services that the patient  100  agrees to pay to the provider  110  in full at the point of service using a dedicated medical credit card  195 . In one embodiment, a medical credit card  195  is different from a regular credit card in that charges made to the medical credit card  195  will only be approved if the credit card company receives, prior to the request for approval, verification from the price determination system  115  that the charge is for a bona fide medical expense. In one such embodiment, the medical plan card  105  may also be the medical credit card. 
     In one example of a medical credit card health plan, the benefit coverage and payment rules  155  may instruct the price determination system  115  to calculate the payment amount for the encounter, to send payment amount information to the provider office  110  so that the patient  100  can pay the provider  110  using the medical plan/credit card  105  in the provider&#39;s office. The price determination system  115  further sends verification of the encounter and the payment amount to the medical credit card company  195  so that the medical credit card charge will be approved. In such an embodiment, the price determination system  115  may send a verification message to the medical credit card company  195  that comprises patient  100  identification information, provider  110  identification information, and the calculated payment amount. When the associated charge request is received by the medical credit card company  195 , if the patient identification  100 , the provider identification  110 , and the payment amount match those received in the verification message, the charge is approved, and payment is sent to the provider&#39;s bank account  112 . 
     In another example of a medical credit card health plan, in one embodiment the benefit coverage and payment rules  155  may instruct the price determination system  115  to calculate the payment amount for the encounter and then to transmit a charge request directly to the medical credit card company  195 . Once approval of the charge is received by the price determination system  115  from the medical credit card company  195 , the price determination system  115  can transmit this information back to the provider&#39;s office  110 . 
     As another example, a client group&#39;s medical plan may provide access to PPO-negotiated rates for medical goods and services in conjunction with a “purse”  192 , which, for purposes of this description, is a fund of money that is available for payment of a patient&#39;s approved medical expenses. In one embodiment, a purse  192  may be funded by the patient  100  and/or by the patient&#39;s employer. In one embodiment, funds for the purse are deducted on a pre-tax basis from a patient&#39;s  100  paycheck and are available for paying Internal Revenue Service (IRS)-approved medical expenses. Some examples of purses  192  and the names by which they are known are: flexible savings account (FSA), medical savings account, health savings account, and personal care account. In one embodiment, a medical plan card  105  used in conjunction with such a medical plan may also serve as a “stored value card.” 
     In conjunction with this type of health plan, in one embodiment, the client-specific data  120  may further comprise a list of approved medical goods and services, which may be identified by CPT code. The eligibility list  135  may further comprise information about an available balance of funds in the patient&#39;s purse  192 . The benefit coverage and payment rules  155  may instruct the price determination system  115  to consult the list of approved medical goods and services to verify that the encounter is associated with approved goods and services or to calculate an approved portion of the payment amount, if not all of the encounter&#39;s goods and services are approved. The benefit coverage and payment rules  155  may further instruct the price determination system  115  to verify that sufficient funds exist in the purse  192  to cover the approved portion of the calculated payment amount, and, in one embodiment, to submit a claim to the purse  192  so that funds covering the approved portion of the payment amount are deducted from the purse  192  and are deposited in the medical provider&#39;s bank account  112 . In one embodiment, the price determination system  115  can then communicate with the provider&#39;s office  110  via IVRS and/or fax transmission information about the calculated payment amount and about any approved amount paid from the patient&#39;s FSA, or other purse. 
     In addition to the immediate payment advantage thus afforded to the provider  110 , such a medical payment system also provides an advantage to the patient  100  in that the patient  100  need not first pay out of pocket for approved expenses and then later submit a written request for reimbursement, but may have the funds deducted from the purse  192  automatically. 
     In another example, the price determination system  115  may calculate the contracted payment amount on behalf of a third party payor  190  that may be responsible for paying some, all, or none of the payment amount to the provider  110 . A third party payor  190  may be a medical insurance company, a self-insured employer that provides its own insurance for its employees, a third-party administrator for a self-insured employer, or another entity that is responsible for paying some or all of a patient&#39;s medical expenses and that has negotiated for discounted rates available from a set of PPO&#39;s. Thus, in some embodiments, in order to correctly determine and to apportion responsibility for paying the calculated payment amount to the provider  110 , the benefit coverage/payment rules  155  may describe which medical goods and services are covered by the payor  190 , as well as benefit payment levels for those that are covered. 
     For example, some medical plans cover well-baby check-ups, while other medical plans do not. Some plans will pay for 80% of the contracted payment amount for a basic procedure, but only 50% of certain laboratory tests. Some services, such as chiropractic treatments, may be covered for only up to ten visits a year or ten visits per injury. Some plans have an annual maximum that they will pay. Using the benefit coverage/payment rules  155 , client-specific information stored about the patient in the eligibility list  135 , and the calculated payment amount, the price determination system  115  is able to apportion responsibility for paying the provider  110  for the patient encounter. 
     The benefit coverage/payment rules  155  may instruct the price determination system  115  to submit a claim for approved expenses to the third-party payor  190 . In some embodiments, such a claim comprises information desired by the payor, such as, for example, patient  110  and provider  110  identification, and CPT  160  and ICD-9  170  codes associated with the encounter, and calculated payment amount. In some embodiments, the benefit coverage/payment rules  155  will also instruct the price determination system  115  to notify the provider  110  of the claim submission and of any payment amount not included in the claim submission that remains for the patient  100  to pay. 
     In other examples, client groups may provide a medical plan that is a combination of the medical plans described above. For example, a health plan may offer medical insurance coverage  190  in conjunction with an FSA purse  192  that can be used to pay for approved expenses that are not covered by the medical insurance  190 . Or, a health plan may offer medical insurance coverage  190  in conjunction with an FSA purse  192 , as above, with the added feature of a medical credit card  195  that can be used to pay for expenses that are not covered by either the medical insurance  190  or the FSA purse  192 . The flexible nature of the price determination system  115  together with the expressive capabilities of the benefit coverage and payment rules  155  allows the price determination system  115  to serve a wide variety of client groups, each with different memberships, providers, PPO affiliations, and health plans, while providing a universally-available, easy-to-use interface to the provider  110 . In embodiments that access the price determination system  115  via the telephone, accessing the correct information for a given encounter may be achieved quickly and easily by dialing the provided telephone number. 
       FIG. 1  depicts examples of three types of parties or entities that may hold full or partial responsibility for payment of a payment amount calculated by the price determination system  115 . However, as will be familiar to one of ordinary skill in the art, other types and examples of parties and entities desiring information about the calculated payment amount and payment responsibility apportionment determined by the price determination system  115  may also be incorporated in the system and are also envisioned in embodiments of the system described. 
       FIG. 1  depicts the client-specific data  120  and the price calculation data  125  that is used by the price determination system  115  as being stored within the price determination system  115 . However, as will be familiar to one of ordinary skill in the art, in other embodiments, some or all of the information may be stored in one or more of the parties or entities  190 ,  192 ,  195  or in another external data storage facility. Accessing some or all of the client-specific data  120  and/or the price calculation data  125  externally may be accomplished using any of a variety of known communications methods, such as, for example, dedicated high-speed and/or high-volume communication lines, telephone networks, wireless data transmission systems, two-way cable systems, customized computer networks, or other data transmission methods. In such embodiments, client-specific rules instruct the price determination system  115  how and where to access the information desired for calculating the contracted payment amount and, if applicable, for processing the payment amount information in accordance with the benefit coverage and payment rules  155  of the client group. 
       FIG. 2A  depicts one embodiment of an eligibility list  135  that may be used by the price determination system  115  to access information about the patient&#39;s  100  eligibility to receive medical goods and services at the client group&#39;s contracted reduced rates. In some embodiments, possession of the card  205  confers eligibility to participate in the medical plan. In some embodiments, client group members pay monthly for access to the benefits of the health plan, and eligibility is determined on a monthly basis. In other embodiments, eligibility is determined based upon other bases, such as, for example, upon continued employment by a given employer. In some embodiments, membership in the client group and eligibility for the contracted reduced rates of the medical plan is demonstrated in ways other than by use of the card  105 . 
     As depicted in  FIG. 2A , the eligibility list  135  comprises information that identifies the patient  100 , such as, for example, a member identification number  205  assigned by the health plan. In some embodiments, a member&#39;s name is used to identify the member. In some embodiments, membership in the client group may be extended to an eligible patient&#39;s  100  family members, and in such embodiments the eligibility list  135  may comprise identifying information about the member who is considered the primary member  210 . Information about an effective start date of eligibility  215  to receive the client group&#39;s contracted reduced rates and a termination date of eligibility  220 , if any exists, may also be stored in the eligibility list  135  and may be used by the price determination system  115  for verifying eligibility and for calculating the contracted payment amount for the patient encounter. 
     In embodiments where one or more parties or entities other than the patient  100  in the provider&#39;s office  110  is responsible for paying at least a portion of the payment amount, the price determination system  115  may also use information in the eligibility list  135  to correctly apportion responsibility for the payment. In such embodiments, the eligibility list  135  may also comprise additional information, such as, for example, a balance amount remaining towards a medical plan&#39;s required deductible amount  225  and a history  230  of medical claims or other information useful for calculating and apportioning responsibility for a contracted payment amount. Information in the eligibility list  135  may be updated as best suits the needs of the client group, and in various embodiments, the eligibility list  135  is updated daily, weekly, or monthly. 
       FIG. 2B  depicts one embodiment of a provider list  140  that may be used by the price determination system  115  to determine with which PPO&#39;s the provider  110  is affiliated and to verify that the provider  110  is affiliated with at least one of the PPO&#39;s that comprise the medical plan for the client group. The provider list  140  may also be used to identify a bank account  112  associated with the provider  110  into which funds as payment for contracted payment amounts may be deposited. The provider list may also store and provide other provider-related information as desired by the individual client groups. 
     As depicted in  FIG. 2B , the provider list  140  comprises identifying information  235 , which in  FIG. 2B  is embodied as the providers&#39; tax identification numbers. Identification information can also be embodied in different forms, and in some embodiments, the provider list  140  stores identification for the provider  110  as well as for a group, such as a hospital or doctor&#39;s group, to which the provider  110  belongs. Bank account information  241  allows for direct deposit of payment amounts in the provider&#39;s bank account  112 , and zip code information  242  allows for accurate calculation of the payment amount when it is based, all or in part, on the provider&#39;s geographic location. The provider list  140  also comprises a list of the PPO affiliations  240  for each provider  110 , which is used by the price determination system  115 , in conjunction with the priority list  145  that will be described with reference to  FIG. 2C , to identify an appropriate PPO whose fee schedule  150  will be used to calculate the contracted payment amount, as will be described in greater detail below with respect to  FIGS. 3 and 5 . 
     As was described above, a medical plan may comprise fee schedules  150  that have been negotiated with providers  110  by a plurality of PPO&#39;s. As was also described above, a provider  110  is often affiliated with a plurality of PPO&#39;s and may have contracted with different PPO&#39;s to provide goods and services at varying rates. In one embodiment, in order to know which contracted payment rate applies to goods or services offered by a provider  110  to a patient in a given client group, the client group builds its medical plan as a hierarchy of PPO fee schedules  150  that is encoded in the priority list  145 . Thus, a PPO in the health plan is assigned a ranking, and providers  110  who serve patients  100  in the client group agree to accept the fee schedule negotiated with the health plan&#39;s top-ranking PPO, if the provider  110  is affiliated with the top-ranking PPO, and otherwise with the highest-ranking PPO with which the provider  110  is affiliated. 
       FIG. 2C  depicts one embodiment of a priority list  145  that is used by the price determination system  115  to determine which fee schedule  150  to use for calculating the contracted payment amount. As depicted in the example in  FIG. 2C , the priority list  145  comprises the list of PPO&#39;s  250  whose fee schedules are used by the health plan, as well as a ranking  245  for each PPO. Using the priority list  145 , along with any applicable rules from the client-specific benefit coverage and payment rules  155 , allows the price determination system  115  to know what fee schedule  150  to use to calculate a payment amount when the provider  110  is affiliated with more than one PPO, as is often the case. 
     In some embodiments, the PPO affiliations  240  associated with a given provider identification  235  are organized in an ordered format. For example, in embodiments where the PPO&#39;s in the PPO affiliation list  240  are listed by business name, the PPO&#39;s may be listed alphabetically by business name. In embodiments where the PPO&#39;s in the list  240  are given an identification number, the PPO&#39;s in the list can be listed, for example, in ascending or descending numerical order. In the embodiment shown in  FIG. 2B , the PPO&#39;s are identified by alphanumeric code names (for example, PPO-1, PPO-2), and the lists of PPO affiliations  240  are ordered in ascending order of the numeric portion of the code names. Thus, the PPO affiliation list  240  for the provider  110  with tax identification number “22-222-22” begins with PPO-2, PPO-7, and PPO-22. The PPO affiliation list  240  for the provider  110  with tax identification number “ 44 - 444 - 44 ” begins with PPO-2, PPO-3, and PPO-7. In other embodiments, the PPO affiliations list  240  may be stored in an unordered format. The PPO affiliations list  240  for provider “22-222-22” is compared with the ranked list of PPO&#39;s  250  in the priority list  145  to ascertain the highest ranking PPO amongst the affiliates of provider “22-222-22.” In the priority list  145  of  FIG. 2C , the top ranking PPO is PPO-3, follow next by PPO-2 in second place, and PPO-7 in third place. 
     For example, to continue with our example of provider “22-222-22” from  FIGS. 2B and 2C , in one embodiment, the PPO affiliations  240  from the provider list  140  are searched first for the presence of the top-ranking PPO. In this example, the top ranking PPO in the priority list is PPO-3, and the PPO affiliations list  240  for provider “22-222-22” can be searched for the presence of a listing for PPO-3. 
     If the PPO affiliations list  240  is ordered, as it is in  FIG. 2B , a computer-implemented search beginning at the start of the list  240  can attempt to find PPO-3 in the list  240  and can determine, once the listing for PPO-7 has been reached without encountering a listing for PPO-3, that PPO-3 does not exist in the list  240 . Therefore, the search for PPO-3, the highest ranking PPO in the priority list  145 , among the PPO affiliations  240  of provider “22-222-22” need not be continued. 
     If the PPO affiliations list  240  is unordered, then a computer-implemented search can be made of the entire list  240 , to see if PPO-3 is present in the list. 
     If a search determines that the highest-ranking PPO is not present amongst the affiliations  240  of provider “22-222-22,” then a new search can be initiated, this time for the second-ranking PPO from the priority list. In the examples of  FIG. 2C , the second-ranking PPO is PPO-2, and a search of the PPO affiliations list  240  for provider “22-222-22” reveals that PPO-2 is amongst the PPO&#39;s listed for provider “22-222-22.” Thus, PPO-2 is the highest-ranking PPO affiliation for provider “22-222-22,” and the fee schedule  150  associated with PPO-2 will be used to determine the negotiated payment amount for the encounter. 
     Continuing with the example embodiments of  FIGS. 2B and 2C , if the provider  110  with tax identification number “44-444-44” submits a price determination request to the same health plan for an identical encounter, the PPO-2 fee schedule  150  is not used, although provider “44-444-44” is also affiliated with PPO-2. The fee schedule  150  for PPO-3 is used, because when the PPO affiliations for provider “44-444-44” are searched for PPO-3, the highest-ranking PPO in the priority list  145 , the search reveals that provider “44-444-44” is affiliated with PPO-3. Thus, PPO-3 is the highest-ranking PPO in the health plan with which provider “44-444-44” is affiliated, and the fee schedule for PPO-3 is used to determine the negotiated payment amount for the encounter. 
     Each client group&#39;s health plan may comprise a different set of PPO fee schedules and may order them in a different hierarchy. Thus, provider “22-222-22” and provider “44-444-44” may submit price determination requests for the same encounters as in the first example above to another client group&#39;s health plan, and may have their negotiated payment amounts calculated according to different fee schedules than those that were used in the first example. For example, if a health plan&#39;s priority list  145  comprises PPO-7, PPO-22, and PPO-45 as the three top-ranked PPO&#39;s, then a search of the affiliated PPO lists  240  for provider “22-222-22” and for provider “44-444-44” reveals that they both are affiliated with PPO-7, and they will thus both have their payment amounts calculated using the fee schedule  150  of PPO-7. 
     In another embodiment of a priority list  145 , the list  145  for a given health plan may provide a ranking that is geographically based. For example, the priority list  145  may specify, for providers  110  in a geographical area defined by a grouping of postal zip codes, that a certain ranking of PPO&#39;s be used for selecting a fee schedule  150 , while for providers  110  in another geographical area, defined by a different grouping of postal zip codes, another ranking of the PPO&#39;s be used to select the fee schedule  150 . This type of geographically-based priority list  145  can reflect the fact that many PPO&#39;s are also geographically based, which is to say that they represent a network of providers within a limited geographical area, rather than being a national network with providers spread across the country. Using this type of embodiment, a health plan can, for example, structure its priority list  145  to always give highest ranking to locally based PPO&#39;s. When a provider  110  requests a price determination, the priority list  145  is consulted using the provider&#39;s  110  zip code in order to access the health plan&#39;s ranking of PPO&#39;s for that zip code. Thus, the highest-ranking PPO amongst the provider&#39;s  110  PPO affiliations  240  can be ascertained, and the appropriate fee schedule  150  for the price calculation can be located. 
     In another embodiment, in locations where such a health plan structure is permissible by law, a health plan may structure its priority list  145  to select the PPO fee schedule  150  that reflects the lowest cost to the patient or other payor. In such an embodiment, the priority list  145  may be organized by CPT code, such that for a given CPT code, or grouping of CPT codes, a ranked priority list  145  of PPO&#39;s is provided to reflect the PPO&#39;s that have negotiated the lowest payment amount for the given services or goods. With this type of embodiment, when a provider  110  requests a price determination, the priority list  145  is consulted using the CPT code identified by the provider  110  as describing the patient encounter for which pricing is requested. Thus, the health plan&#39;s cost-based ranking of PPO&#39;s for the given service or goods can be used to determine the appropriate fee schedule  150  to use for the payment amount calculation. 
     Three embodiments of PPO hierarchies and their associated priority lists have been described as examples. Other hierarchy systems are possible and priority lists  145  to suit the hierarchy systems can be created, as will be appreciated by one of ordinary skill in the art. 
       FIGS. 2A, 2B, and 2C  depict examples of data structures that can be used to store data for the price determination system  115 . However, the data used by the price determination system  115  may also be stored as other types of flat files, as relational or object-oriented data structures, or as other appropriate structures. As will be familiar to one of ordinary skill in the art, the structure, organization, and content of the data may be embodied in different forms to serve the various embodiments of the medical payment system, without departing from the spirit of the medical payment system described herein. In some embodiments, some or all of the eligibility list  135 , the provider list  140 , and the priority list  145  are implemented as computer modules. 
       FIG. 3  is a flowchart that depicts one embodiment of a medical payment system  300  that allows a medical provider  110  to contact a price determination system  115  and to receive from the price determination system  115  the correct negotiated payment amount for a patient encounter. From a start state, the medical payment system  300  proceeds to state  310 , in which the medical provider  110  contacts the price determination system  115 . In one embodiment, the provider  110  contacts the price determination system  115  by dialing a phone number printed on the patient&#39;s  100  medical plan card  105  and by thereby being connected to an interactive voice response system (IVRS) associated with the price determination system  115 . In one embodiment, the telephone number is not printed on the medical plan card  105 , and the provider  110  has access to the number for connecting to the IVRS from another source. In one embodiment, the provider  110  contacts the price determination system  115  by dialing a phone number printed on the patient&#39;s  100  medical plan card  105  and speaking to an operator. In one embodiment, the provider  110  contacts the price determination system  115  using a computer network. In other embodiments, other methods of communication, such as dedicated phone lines or wireless communications systems, are used by the provider  110  to contact the price determination system  115 . 
     Moving on to state  320 , once the medical provider  110  has contacted the price determination system  115 , the medical provider  110  inputs information about the patient encounter for which the provider  110  wishes to receive a contracted payment amount. In one embodiment where the provider  110  has contacted the price determination system&#39;s  115  IVRS via telephone, the provider  110  is prompted by oral instructions transmitted from the IVRS to input the patient encounter information using the keypad on the telephone. In one embodiment, the IVRS prompts the provider  110  to input the patient encounter information orally, and the price determination system  115  uses a voice recognition system to encode the information into a format usable by the price determination system  115 . In other embodiments, the provider  110  inputs the patient encounter information using a computer keyboard or other computer input system.  FIG. 4  describes in greater detail one embodiment of an encounter information input system. 
     Moving on to state  330 , once the medical provider  110  has input the patient encounter information, the price determination system  115  identifies the appropriate fee schedule for the encounter. In state  340 , the price determination system  115  uses information from the identified fee schedule to calculate the contracted payment amount for the encounter. The actions of states  330  and  340  are described in greater detail with reference to  FIG. 5  below. 
     Moving on to state  350 , once the price determination system  115  has calculated the contracted payment amount for the encounter, the price determination system  115  communicates the payment amount to the provider  110  and to any parties or entities responsible for paying the provider, as indicated by the benefit coverage and payment rules  155  that were described with reference to  FIG. 1 . In one embodiment, where the provider  110  communicates with the price determination system  115  using an IVRS, the price determination system  115  transmits an oral message over the telephone, informing the provider  110  of the payment amount. In one embodiment, the price determination system  115  may also offer an option of having a record of the calculated payment amount faxed to the provider&#39;s office  110  so that the provider  110  can have a paper copy of the information exchanged and the calculated payment amount. 
     Communicating the calculated payment amount to the provider&#39;s office  110  at the time of service allows the provider  110  to present an accurate bill for the encounter to the patient  100  at the time of service, thereby enabling the patient  100  to pay the provider  110  before leaving the office. This capability represents a great improvement over current medical payment systems in which the provider  110  may typically wait three to six months to receive payment for an encounter. In one embodiment, as a condition of receiving the medical plan card  205  and access to the reduced rates that it represents, the patient  100  agrees to pay his or her portion of the calculated payment amount, in full or as otherwise agreed upon with the provider  110 , at the time of service. 
     When one or more parties or entities, such as, for example, a third party payor  190 , a purse  192 , or a medical credit card account  195 , is responsible for paying all or part of a calculated payment amount, the price determination system  115  may be instructed by the benefit coverage and payment rules  155  to submit a claim or a notification to the one or more responsible parties or entities. Communication with the responsible parties or entities  190 ,  192 ,  195  may take place via a dedicated high-speed, high-volume data line, via telephone connection, via computer network connection, or via another communications method. Instructions regarding the content of the claim or notification communication may be provided to the price determination system  115  by the benefit coverage and payment rules  155 , so that the price determination system  115  is able to accommodate a variety of types of responsible parties and entities  190 ,  192 ,  195 . When instructed by the benefit coverage and payment rules  155 , the price determination system  115  can wait for feedback, such as a confirmation, from the responsible parties or entities  190 ,  192 ,  195  and can transmit an appropriate message to the provider&#39;s office  110  using the IVRS, the fax, or other chosen communications method. Such an appropriate message may, in some embodiments, be a simple confirmation of the actions taken by the price determination system  115 , and may, in some embodiments, provide information about a portion of the payment amount still remaining for the patient  100  to pay. 
     Other embodiments can allow the price determination system  115  to process the calculated payment amount in different ways. In one embodiment, claims for submission to responsible parties  190 ,  192 ,  195  for payment are batched and are sent to the responsible parties once a day, or as is otherwise deemed desirable. In one embodiment, information is stored in a table with the client-specific data  120  that describes a price determination request for a given encounter and information about the amount of savings received by the patient  100  over the provider&#39;s standard billing rate for the encounter. Such information may be provided to the client group or to another interested, authorized party for assessing the value of the medical plan to its members. 
     The flowchart of  FIG. 3  has depicted one embodiment of a medical payment system. As will be clear to one of ordinary sill in the art, other embodiments of the medical payment system may be implemented that arrange the states of the system in other configurations, that add or delete states as appropriate, that divide the system into different states, or that exhibit a combination of these changes without departing in spirit from the medical payment system described herein. 
       FIG. 4  presents a flowchart that depicts one embodiment of an interactive voice response system (IVRS)  400  that can be used by a price determination system  115  to receive encounter information from a provider  110  and to transmit an associated calculated payment amount back to the provider  110  and, if appropriate, to other associated parties and/or entities  190 ,  192 ,  195 . 
     In one embodiment, communication from the provider  110  to the IVRS  400  is carried out using a touch-tone telephone keypad, and communication from the IVRS  400  to the provider  110  is carried out by recorded voice messages. Allowing the provider  110  to use the telephone keypad to enter the encounter information, which, in one embodiment, is encoded numerically, provides an accurate, quick, and easy-to-use method for inputting the encounter information. Using the keypad to enter encounter information draws upon knowledge that is common to workers in a medical provider&#39;s office  110  and does not require computer literacy or computer equipment on the part of the provider  110 . Configuring the IVRS  400  to communicate verbally with the provider  110  in order to convey both instructions for use of the system and the calculated payment amount provides a familiar, easily understandable method for communicating with the provider  110 . In one embodiment, additional communication from the IVRS  400  to the provider  110  may be carried out by fax transmission, especially at the end of the price determination for providing a summary in printed format of the price determination for the encounter. 
     In other embodiments, other methods of communication may be implemented for communications from the provider  110  to the price determination system  115 , from the price determination system  115  to the provider, and from the price determination system  115  to any other relevant party or entity  190 ,  192 ,  195 . 
     For the embodiment depicted in  FIG. 4 , beginning at state  402 , the IVRS  400  greets the provider  110 . Moving on to state  406 , the IVRS  400  prompts the provider to enter the patient&#39;s  100  member identification number. In one embodiment, the patient&#39;s  100  member identification number is assigned by the client group&#39;s health plan and is printed on the patient&#39;s  100  medical plan card  105 . In one embodiment, the IVRS  400  prompts the provider to enter identifying information other than a member identification number for the patient  100 . Having access to identifying information for the patient  100  allows the price determination system  115  to verify the patient&#39;s  100  eligibility for the medical plan and, where applicable, allows the system  115  to access information about the patient&#39;s deductible balance remaining and prior claim history or other relevant patient-specific information. 
     Moving on to state  410 , the IVRS  400  prompts the provider  110  to enter identifying information for the provider  110 . In the embodiment shown in  FIG. 4 , the provider&#39;s federal tax identification number is used as a readily available and standard-formatted identifier. In other embodiments, other forms of identification may be used for identifying the provider  110 . Identifying the provider  110  allows the price determination system  115  to access information about the provider&#39;s  110  PPO affiliations, the provider&#39;s bank account information  112 , and the provider&#39;s contact information, geographic location, and other relevant provider-specific information. 
     In the embodiment shown in  FIG. 4 , the IVRS  400  proceeds to state  414 , where the patient  100  identification information and the provider  110  identification information are sent to a host processor. In embodiments where the telephone number dialed by the provider  110  automatically connects the provider  110  to the client-specific data  120  indexed by the client group access number  130 , having the patient  100  identification information allows the processor to begin accessing stored data that is used to verify patient  100  eligibility, so that the provider  110  can be notified promptly if the patient  100  is determined not to be eligible for the benefits of the client group&#39;s health plan. 
     Being connected to the client-specific data  120  also allows the processor to access the health plan&#39;s hierarchy of PPO&#39;s, as expressed in its priority list  145 . Based on the type of PPO hierarchy used by the health plan, having the provider  110  identification information may allow the processor to begin locating the fee schedule  150  that will be used by the price determination  115  system for calculating the payment amount. For example, for health plans with PPO hierarchies similar to the example illustrated in  FIG. 2C , having access to the provider  110  identification information allows the price determination system  115  to gain access to the provider&#39;s  110  list of PPO affiliations  240 . Comparing this list  240  to the priority list  145  allows the price determination system  115  to identify the appropriate fee schedule  150 . 
     In one embodiment, to identify the appropriate fee schedule  150 , the price determination system  115  determines if the health plan&#39;s highest-ranking PPO is among the provider&#39;s  110  affiliates. If so, the processor locates and loads the associated fee schedule  150 . If not, the price determination system  115  identifies the second-ranking PPO in the health plan&#39;s priority list  145  and once again makes a comparison with the provider&#39;s  110  PPO affiliations list  240 . The price determination system  115  determines if the second-ranking PPO is the amongst the provider&#39;s affiliates. If so, the second-ranking PPO is therefore the highest ranking PPO available amongst the provider&#39;s  110  affiliations  240 , and its fee schedule  150  is used for price determination. If it is not, this search process continues until the highest-ranked PPO that is both on the priority list  145  and on the provider&#39;s PPO affiliation list  120  is located. 
     Once the appropriate fee schedule  150  is identified, the price determination system  115  can already, “in the background,” access the fee schedule  150 , which will be used to calculate a payment amount for any procedure codes entered for the encounter. Fee schedules  150 , which typically comprise a large volume of complex data, can sometimes be unwieldy and slow to load, and loading the fee schedule “in the background” while the provider  110  continues to communicate with the IVRS thus enhances the response speed of the system. 
     Other embodiments of the priority list  145  also allow for an “in the background” loading of the fee schedule. 
     For example, in embodiments where the PPO hierarchy is geographically-based, and where the provider list  140  comprises zip code information  242  for the provider  110 , having access to the provider identification  235  allows the price determination system  115  to ascertain the provider&#39;s zip code  242  and to use that information to locate the associated PPO priority list  145 . As with the previous example, having access to the priority list  145  and to the provider&#39;s  110  list of PPO affiliations  240  allows the price determination system  115  to identify the appropriate fee schedule  150 . 
     In one embodiment in which the priority list  145  is based at least in part on the CPT codes entered by the provider  110 , locating and loading the appropriate fee schedule  150  is deferred until CPT information is entered that will allow the appropriate fee schedule  150  to be located. 
     Moving on to state  418 , in the embodiment shown in  FIG. 4 , the IVRS  400  prompts the provider  110  to enter information about a medical diagnosis associated with the encounter. One commonly used numeric code for communicating about medical diagnoses is called the International Classification of Diseases (9 th  Edition) code (ICD-9), and in one embodiment, the diagnosis information is entered using an ICD-9 code. In one embodiment, providing the price determination system  115  with information about the diagnosis associated with the encounter allows the system  115  to accurately determine coverage and payment levels for claims, such as medical insurance claims, that are based at least in part on diagnosis information. 
     Moving on to state  422 , the IVRS  400  determines whether or not the host was able to locate the appropriate fee schedule  150  for the encounter. If the appropriate fee schedule  150  was not found, the IVRS  400  proceeds to state  426 , where the provider  110  is transferred to a live customer service representative for completion of the price determination request. If the appropriate fee schedule  150  has been located, the IVRS  400  proceeds to state  430  where the fee schedule  150  is accessed. 
     Moving on to state  437 , the IVRS  400  prompts the provider  110  to enter information about a medical good or service associated with the patient encounter. One commonly used numeric code for communicating about medical goods and services is the Common Procedure Terminology (CPT) code. A CPT Modifier Code for use in conjunction with the CPT code can be used to expand the expressive capabilities of the CPT codes. In one embodiment, the medical goods or services information is entered using a CPT code and, if desired, a CPT modifier code. Providing the price determination system  115  with information about the medical goods or services associated with the encounter allows the system  115  to accurately determine a contracted payment amount. 
     In the embodiment shown in  FIG. 4 , the IVRS  400  prompts the provider  110  to enter additional information in response to inputted CPT codes for procedures associated with surgery, anesthesia, laboratory work, and radiology, as is described with reference to states  438 - 444 . CPT codes are often grouped numerically into five classes that allow for easy identification of surgery, anesthesiology, laboratory, and radiology procedures. In other embodiments, other CPT codes may receive special treatment, as suits the preferences of the client group&#39;s medical plan. 
     Referring first to state  438 , the IVRS  400  determines if the CPT code entered by the provider  110  in state  437  is a surgery code. If the CPT code is determined to be a surgery code, the IVRS  400  proceeds to state  439 , where the provider  110  is prompted to indicate if the surgery is an assisted surgery. In one embodiment, if the provider  110  indicates that the surgery was assisted, meaning that the provider  110  served as an assistant surgeon in the surgery, then the price determination system  115  is given this information. In one embodiment, the information is requested because an assistant surgeon is typically compensated at a percentage of the allowed payment amount for the primary surgeon. In state  440 , the provider  110  is prompted to enter the provider&#39;s standard billed amount for the surgery, rounded to the nearest dollar, and the IVRS  400  proceeds to state  445 , where the provider is prompted to indicate whether there are more CPT codes to enter in association with this encounter. 
     Returning to state  439 , if the provider  110  responds that there are multiple surgery codes to enter, then the IVRS  400  proceeds to state  445 , where the IVRS  400  cycles back to state  437  and the provider  110  is prompted to enter another CPT code. In one embodiment, the price determination system  115  has been alerted at this point that subsequent surgery codes entered are for secondary surgeries performed in conjunction with a primary surgery, because secondary surgeries are typically compensated at a lower payment amount than primary surgeries. 
     If, in state  438 , the IVRS  400  determines that the CPT code entered in state  437  is not a surgery code, the IVRS  400  proceeds to state  441 , where the IVRS  400  determines if the CPT code entered in state  437  is an anesthesia code. If the CPT code is determined to be an anesthesia code, the IVRS  400  proceeds to state  442 , where the provider  110  is prompted to enter the length of time of the anesthesia procedure in whole minutes. Entering the time length for the anesthesia procedure can be accomplished easily using a telephone keypad and allows for proper calculation of the contracted payment amount for an anesthesia procedure. 
     If, in state  441 , the IVRS  400  determines that the CPT code entered in state  437  is not an anesthesia code, the IVRS  400  proceeds to state  443 , where the IVRS  400  determines if the CPT code entered in state  437  is a laboratory or radiology code. If the CPT code is determined to be a laboratory or radiology code, the IVRS  400  proceeds to state  444 , where the provider  110  is prompted to indicate by means of CPT modifier code  165 , whether the price determination request is for service rendered by a technician, such as a blood draw, which is considered a “technical component” and is compensated at one rate, or is for service rendered by a physician, such as analysis of blood test results, which is known as a “professional component” and is compensated at another rate. 
     If, in state  443 , the IVRS  400  determines that the CPT code entered in state  437  is not a laboratory or radiology code, the IVRS  400  proceeds to state  445 , where the IVRS  400  prompts the provider  110  to indicate whether the provider  110  has more CPT codes to enter in association with the patient encounter for which a payment amount is being requested. 
     If, in state  445 , the provider  110  indicates that there are additional CPT codes to be entered in conjunction with the payment amount calculation request for the current patient encounter, the IVRS  400  returns to state  437  where the IVRS  400  prompts the provider  110  to enter a CPT code. The IVRS  400  continues to cycle through states  437 - 445  until the provider  110  indicates that there are no further CPT codes to enter in association with the current payment amount request. 
     When, in state  445 , the provider  110  indicates that there are no further CPT codes to enter in association with the current payment amount request, the IVRS  400  proceeds to state  470 , where the IVRS  400  transmits the information that was received from the provider  110  about the patient  100 , the provider  110 , the diagnosis (ICD-9), and the goods and services (CPT&#39;s) associated with the encounter to a host processor for the price determination system  115 . 
     In one embodiment, the IVRS  400  proceeds to state  474  where the IVRS  400  plays a message indicating the calculated pricing information to the provider  110  over the telephone. In the embodiment shown in  FIG. 4 , the IVRS  400  may additionally or alternatively fax the calculated pricing information to the provider  110 . 
     Moving on to state  478 , the price determination system  115  sends the calculated payment information and any associated information indicated by the benefit coverage and payment rules  155  to any responsible parties and/or entities indicated in the benefit coverage and payment rules  155  as was described with reference to  FIG. 1 . 
     Moving on to state  482 , the IVRS  400  prompts the provider  110  to indicate whether there are more claims to price for this patient. If the provider  110  indicates that there are one or more claims to price, the IVRS  400  proceeds to state  437 , where the provider  110  is again prompted to enter a CPT code and to proceed as was described above. If, in state  482 , the provider  110  indicates that there are no more claims to price for the patient  100 , the IVRS proceeds to state  486 , where the IVRS  400  indicates to the provider  400  that the interaction is completed, and the communication is terminated. 
     The flowchart of  FIG. 4  depicts one embodiment of an encounter information input system. As will be clear to one of ordinary skill in the art, other embodiments of the encounter information input system may be implemented that arrange the states of the system in other configurations, that add or delete states as appropriate, that divide the system into different states, or that exhibit a combination of these changes without departing in spirit from the encounter information input system described herein. 
       FIG. 5  is a flowchart that depicts one embodiment of a method  500  that can be carried out by a price determination system  115  to determine a contracted payment amount for a patient encounter. The embodiment shown in  FIG. 5  corresponds generally to states  330  and  340  of the medical payment system  300  described with reference to  FIG. 3  above. 
     The method  500  of  FIG. 5  begins in state  510  where the price determination system  115  verifies the eligibility of the patient  100  to receive the benefits of the medical plan associated with the client group access number  130 . In one embodiment, the price determination system  115  accepts member identification information about the patient  100  from the provider  110  and uses the identification information to access eligibility information about the patient  100  stored in an eligibility list  135 , as was described in greater detail with reference to  FIG. 2A . For example, in embodiments in which information about the patient&#39;s effective date  215  of coverage and termination date  220  is stored in the eligibility list  135 , the price determination system  115  verifies that the current date is later than the effective date  215  and that the current date is earlier than the termination date  220 , if any termination date  220  is listed. 
     Once the price determination system  115  determines that the patient  100  is eligible to receive the benefits of the medical plan, the price determination system  115  proceeds to state  520  of the method  500 , in which the price determination system  115  uses the medical provider  110  identification information entered by the provider  100  to identify the provider&#39;s  100  PPO affiliations. In one embodiment, the price determination system  115  uses the provider list  140 , as was described in greater detail with reference to  FIG. 2B , to identify the provider&#39;s  110  PPO affiliations. 
     Proceeding on to state  530  of the method  500 , the price determination system  115  uses the PPO affiliation information accessed in state  520  together with information stored in the priority list  145 , as was described in greater detail with reference to  FIG. 2C , to identify which of the provider&#39;s  100  affiliated PPO&#39;s is given the highest priority according to the priority list  145 . This information can be used to identify the fee schedule  150  that is to be used for calculating the payment amount. Basically, the PPO affiliations negotiated by the provider  110  are identified, the hierarchy of the health plan&#39;s PPO&#39;s is identified, and the two are compared in order to determine which of the PPO&#39;s affiliated with the provider  110  has the highest ranking in the health plan&#39;s hierarchy. 
     In various embodiments, identifying which of the provider&#39;s  110  affiliated PPO&#39;s is given the highest priority can be carried out in different ways, depending on the organization, structure, and content of the priority list  145  and of the list of PPO affiliations  240  for each provider  110 . For example, whether the provider&#39;s  110  PPO affiliations are stored in an ordered or an unordered format, as well as the type of data structure used for their storage, will affect the method used for searching for and locating the given provider&#39;s  110  most highly-ranked PPO, as will be familiar to a practitioner of ordinary skill in the art. One simple example of such a search was described with reference to  FIGS. 2B and 2C . 
     Furthermore, the type of hierarchical organization of PPO&#39;s that is used to form the client group&#39;s health plan will affect the method used in state  530  to determine which PPO&#39;s fee schedule  150  is to be used for calculating the payment amount due to the provider  110 . 
     For example, as was described with reference to  FIG. 2C , in embodiments where the health plan is organized such that for each geographical location served, a different ranking of the PPO&#39;s is used, then searching for the highest-ranking PPO may comprise identifying the zip code  242  associated with the provider  110  and identifying the portion of the priority list  145  associated with that zip code. 
     In other embodiments, one ranking of PPO&#39;s may be used for all geographical areas except for one area, in which, for example, a self-insuring employer has negotiated special rates with medical providers and for which another ranking exists. In such an embodiment, the benefit coverage and payment rules  155  may instruct the price determination system  115  to use the zip code  242  of the provider  110  who is submitting a price determination request to access the desired ranking of PPO&#39;s in the priority list  145 . 
     As was also described with reference to  FIG. 2C , in some embodiments where such arrangements are permissible, the health plan is organized such that the payment amount negotiated by the PPO that offers the lowest price for the services or goods associated with the patient encounter is the amount used as the contracted amount. In such embodiments, searching for and locating the appropriate fee schedule comprises identifying the CPT code or other procedure/goods identifier associated with the patient encounter and identifying the portion of the fee schedule  150  that gives a ranking of PPO&#39;s for that procedure identifier. 
     Procedure identifiers such as CPT codes may also be relevant to the search for an appropriate fee schedule  150  in embodiments where a given PPO does not provide a negotiated rate for the services or goods associated with the patient encounter. For example, a given PPO may not have negotiated a payment amount for eye examinations with its affiliated providers. Thus, even if the given PPO is listed in the priority list  145  as having the highest ranking in general, for patient encounters that involve an eye examination, the fee schedule associated with the PPO that has the next highest ranking and that does provide a contracted rate for eye examinations will be used. As will be familiar to a practitioner of ordinary skill in the art, the priority list  145  can be modified to express such a hierarchy. 
     Other embodiments may use other methods and information sources to search for an appropriate fee schedule, as encoded in the instructions of the benefit coverage and payment rules  155 . For example, in one embodiment, a client group may choose to give the highest ranking to the PPO, from amongst those that make up its health plan, that contracts with the largest number of providers, and to rank the other PPO&#39;s in its health plan according to the number of providers in their network, as well. Information about the number of contracted providers participating in each PPO&#39;s network may be provided to the price determination system  115  on a daily, weekly, monthly, yearly or other basis, so that the priority list  145  in such an embodiment may be kept up-to-date. 
     Handling exceptions and anomalies in the selection of fee schedule  150  for use in price determination can be carried out in a variety of ways, as expressed by the benefit coverage and payment rules  155  for a given client group. In some embodiments, if a provider  110  does not appear in the client group&#39;s provider list  140 , or if the identified provider  110  has no associated PPO affiliations that appear in the priority list  145 , then the price determination request submitted by telephone, computer, or other communications method is forwarded to a human representative for price determination. In some embodiments, the price determination request is rejected, and a message is transmitted to the provider&#39;s office  110  that no payment amount for the encounter can be calculated using the price determination system  115 . 
     In some embodiments, the benefit coverage and payment rules  155  for a given client group specify a default method of handling such anomalies or exceptions. In one embodiment, a default flat fee for each CPT code may be specified. In another embodiment, a fixed percentage of the provider&#39;s standard billing rate for the given service or good may be specified. In such an embodiment, the IVRS or other communications method may need to prompt the provider  110  to enter the standard billing rate for the given service or good. In other embodiments, exceptions and anomalies are handled using other methods that will be familiar to one of ordinary skill in the art. 
     Proceeding to state  540  of the method  500 , the price determination system  115  accesses the fee schedule  150  for the PPO that was identified in state  530  as being the PPO with the highest priority from amongst the provider&#39;s  110  PPO affiliations. In one embodiment, the price determination system  115  uses the fee schedule  150  to determine the contracted calculation methodology agreed upon by the provider  110  and the provider&#39;s highest priority PPO for the medical goods and/or services with the CPT codes input by the provider  110  for the patient encounter. 
     Once the calculation methodology agreed upon by the provider  110  and by the PPO has been identified, the price determination system  115  proceeds to state  550  of the method  500  and uses the identified calculation methodology to calculate the contracted payment amount for the goods and services identified by the provider  100  as being associated with the patient encounter. In some embodiments, the CPT information  160  stored in the price calculation data  125  is accessed to identify the multiplier values for the entered CPT codes, as was described with reference to  FIG. 1 . In some embodiments, zip code information  180  and/or Medicare payment rate information  175  is accessed in order to calculate the contracted payment amount for the encounter. 
     Once the contracted payment amount has been calculated, the medical payment system  300  of  FIG. 3  can use the payment amount information together with information stored in the client group&#39;s benefit coverage and payment rules  155  to apportion, amongst one or more parties or entities  100 ,  190 ,  192 ,  195 , the responsibility for paying the payment amount to the provider  110 . The medical payment system  300  can further communicate with the one or more parties or entities  100 ,  190 ,  192 ,  195  in order to notify them of the portion of the payment amount for which they are responsible to pay. 
     The flowchart of  FIG. 5  has depicted one embodiment of a method to determine a negotiated payment amount for a patient encounter. As will be clear to one of ordinary skill in the art, other embodiments of the payment amount determination method may be implemented that arrange the states of the system in other configurations, that add or delete states as appropriate, that divide the system into different states, or that exhibit a combination of these changes without departing in spirit from the payment amount determination method described herein. 
     For ease of explanation, some simplifying assumptions have been made in the foregoing detailed description. For example, one-to-one correspondences have been assumed between the provider  110  and the provider bank  112 , between a client group and the associated medical plan, and between a PPO and the associated priority list. Thus, for purposes of this description, for example, sending a payment to a provider&#39;s bank account  112  is equivalent to sending payment directly to the provider  110 . Similarly, for purposes of this description, because the aspect of interest with respect to the client group is the medical plan that it offers its members, the terms client group and medical plan may be used interchangeably in some instances. Furthermore, the one-to-one correspondence assumed in this description for ease of explanation implies that a hierarchy or priority list of PPO&#39;s may also be seen as a hierarchy or priority list of the associated fee schedules. In other embodiments, these one-to-one correspondences may not hold true without departing from the spirit of the medical payment system described herein. 
     While certain embodiments of the inventions have been described, these embodiments have been presented by way of example only, and are not intended to limit the scope of the inventions. Indeed, the novel methods and systems described herein may be embodied in a variety of other forms; furthermore, various omissions, substitutions and changes in the form of the methods and systems described herein may be made without departing from the spirit of the inventions. The accompanying claims and their equivalents are intended to cover such forms or modifications as would fall within the scope and spirit of the inventions.