Patent Publication Number: US-2013238362-A1

Title: Health care patient benefits eligibility research system and methods

Description:
CLAIM OF PRIORITY 
     This application claims priority from U.S. Provisional Patent Application No. 60/654,028 entitled “Health Care Patient Benefits Eligibility Research System and Business Method” filed on behalf of John Wester, on Feb. 17, 2005 (Attorney Docket No. E-Scan Prov). 
    
    
     TECHNICAL FIELD 
     The invention relates generally to data processing software for inquiring and determining eligibility for reimbursement for patients by comparing the patient information against a benefit provider&#39;s database of covered persons to determine if the patient is eligible for benefits and, if so, associating the patient record with the matching record in the benefit provider&#39;s database so the service provider can seek to be reimbursed for the services provided to the patient. 
     BACKGROUND 
     The provision of health care services in the United States has become the focus of much attention. With the costs of medical malpractice insurance spiraling, and the payments being made to health care providers from benefit providers, including private and government insurers being reduced continually, health care providers are finding it necessary to get payments for all the services they actually render. 
     Unfortunately, many health care providers are not receiving compensation for the services they render. This could be due to a number of factors, such as patients not having the ability to pay for the services, and/or not having any medical payment system or insurance. In other instances, medical care service providers submit a request to determine if a patient is eligible for coverage under a private or government insurance plan, but are told the patient is not eligible for coverage. Often, payment for services rendered is denied due to incorrect data entry about a patient and/or the service rendered, through failure to associate the information with the correct patient record in the benefit provider&#39;s database, or other misunderstandings or mis-associations. 
     For medical care service providers, being denied payment for services rendered is problematic, and can, in some cases, mean the difference between profitability and a business that does not show a profit. Typically, such claims which are classified as not eligible for reimbursement are written off as bad debt for which collection cannot be achieved. Ultimately, these costs are either passed along to other patients by means of cost increases, or the care provided is cut back to save or reduce costs. 
     Accordingly, a continuing search has been directed to the development of methods which can help medical care service providers maximize identification of patients who are eligible for private or government medical insurance so the service providers can be reimbursed for claims. 
     Therefore, what is needed is a system and/or method for helping to efficiently identify claims for which the patients are eligible for health care benefits, which can be paid to the health care provider. 
     SUMMARY 
     Normally, claims for medical care are submitted to a patient&#39;s benefit provider for payment. Prior to submitting the claim, the health care provider will need to make an eligibility inquiry to determine whether the person for whom the service was provided is eligible for benefits; if not, payment to the health care provider will be denied. In many cases, the denial is because the information entered on the claim submitted to the benefit provider by the service provider cannot be correlated with the information in the benefit provider&#39;s database because the patient could not be located in the benefit provider&#39;s database due to inconsistencies. In some instances, this is due to a data entry error on the part of the service provider, benefit provider, or both. In other instances, the patient may not be eligible for insurance coverage at the time the services are rendered, or when the eligibility verification inquiry is made. 
     While software already exists that will make an eligibility inquiry to determine eligibility, and inquire as to correlation between records, there has been only partial success with automated eligibility verification inquiries. The existing software has only limited functionality and is not always effective or accurate. It will typically only search for records in which the patient&#39;s name, social security number and date of birth match a record in the benefit provider&#39;s database, and returns a list indicating only those patients for which an exact match has been found. It will not provide information as to numerous other issues that are related to eligibility, such as whether the service rendered is one paid for by the benefit provider. Additionally, manual examination is typically not practical or cost-effective, given the volume of patient claims and records. 
     The present invention provides a software program that will automatically, upon request, query benefit provider databases with a variety of different queries to find persons who are eligible to receive benefits, and who match patients in a service provider&#39;s database for whom services have been or may be provided. The software of the present invention will also automatically segregate those records for which there is a match between the databases for further processing, and can indicate the matching information found in the benefit provider&#39;s database. For example, the software of the present invention can inquire whether the patient is covered by the benefit plan, whether the services provided are covered by the benefit plan, and/or whether the provider is authorized to provide services for persons covered by that benefit plan. 
     The software of the present invention also provides means for comparing records in the benefit provider&#39;s database against a service provider&#39;s claims and finding records that, while not a complete match, have a predefined number of parameters that match, such that upon further analysis and correction, it may be determined that a patient claim is eligible for reimbursement and can be submitted to the benefit provider, and the service provider will be reimbursed for the services performed. The software of the present invention can easily reveal the field or fields in which there is a difference in the information between the service provider&#39;s claim and the benefit provider&#39;s database, making correction of any claim errors much simpler and making the present invention much more cost-effective than prior art which did not reveal any such partial matches, or show errors that had caused a claim that was submitted to have been rejected, but only verified whether or not there was a complete match. 
     The software of the present invention can also show whether the patient was qualified to be covered by a benefit plan at the time the services were rendered. In some instances, the patient was not eligible for coverage at the time the initial inquiry was made, but becomes eligible for coverage at a later time, and the coverage is retroactive back to a period including the time at which the service provider rendered treatment. If this retroactive eligibility is discovered and identified in a timely manner, a request for retroactive reimbursement can be made in some cases. 
     In other cases, even if the eligibility qualification is not discovered in time to seek reimbursement, the un-reimbursed claims can be important for a health care service provider in determining if it is entitled to reimbursement under various government programs for treating uninsured persons, and to help the service provider keep accurate track of how much of such funding they might be entitled to. 
     The present invention can also be used to generate reports in a variety of configurations, as to record matches found, to assist in identifying errors, determining sources of errors, and taking steps to prevent similar future errors. A surprising number of matches between service provider claims and benefit provider databases of persons eligible for reimbursement were found using the software of the present invention that were not found using prior art software. Even when the software of the present invention is used to query the same benefit provider&#39;s database for the same health care provider&#39;s claims, matches are found that were not found when the same or similar queries were previously made. These matches have resulted in tens of millions of dollars of reimbursements for service providers that would have otherwise gone unpaid. 
     The foregoing has outlined rather broadly the features and technical advantages of the present invention in order that the detailed description of the invention that follows may be better understood. Additional features and advantages of the invention will be described hereinafter which form the subject of the claims of the invention. It should be appreciated by those skilled in the art that the conception and the specific embodiment disclosed may be readily utilized as a basis for modifying or designing other structures for carrying out the same purposes of the present invention. It should also be realized by those skilled in the art that such equivalent constructions do not depart from the spirit and scope of the invention as set forth in the appended claims. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       For a more complete understanding of the present invention, and the advantages thereof, reference is now made to the following descriptions taken in conjunction with the accompanying drawings, in which: 
         FIG. 1A  is a high-level conceptual block diagram illustrating the system of the present invention; 
         FIG. 1B  is a detailed block diagram showing the querying of the benefit provider database, including comparison of service provider file records against the benefit provider&#39;s database, and generation of one or more files containing service provider&#39;s records and matching records from the benefit provider database; and 
         FIGS. 2A ,  2 B, and  2 C show samples of some of the types of reports that can be generated from the file containing service provider claims for which there is a matching record in the benefit provider&#39;s database. 
     
    
    
     DETAILED DESCRIPTION 
     In the discussion of the FIGURES, the same reference numerals will be used throughout to refer to the same or similar components. In the interest of conciseness, various other components known to the art, such as computer processing equipment, and the like necessary for the operation of the software, have not been shown or discussed. 
     In the following discussion, numerous specific details are set forth to provide a thorough understanding of the present invention. However, it will be obvious to those skilled in the art that the present invention may be practiced without such specific details. In other instances, well-known elements have been illustrated in schematic or block diagram form in order not to obscure the present invention in unnecessary detail. Additionally, for the most part, details concerning timing considerations and the like have been omitted inasmuch as such details are not considered necessary to obtain a complete understanding of the present invention, and are considered to be within the skills of persons of ordinary skill in the relevant art. 
     It is noted that, unless indicated otherwise, all functions described herein are performed by a processor such as a computer or electronic data processor in accordance with code such as computer program code, software, or integrated circuits that are coded to perform such functions. Additionally, it is noted that the software of the present invention can by used at a computer remote from the benefit provider&#39;s computer system and/or from the service provider&#39;s computer system, or locally to either of these computer systems. 
     A. IMPROVED SYSTEM 
     Referring to  FIG. 1A  of the drawings, the reference numeral  1  generally designates an improved eligibility verification inquiry system of the present invention. The inquiry system  1  comprises unpaid medical claims  100 , software  10 , benefit provider&#39;s database  500 , files of matches  400 , and reports  450  from the files of matches  400 . 
     Normally, claims  100  for medical care are paid for by a patient directly, or submitted to a patient&#39;s benefit provider for payment, such as a private health insurance company, or government-subsidized health care insurance, such as Medicare, Medicaid or other government-funded programs. After processing to verify such things as whether the person for whom the service was provided is covered by the benefit provider, whether the services provided are covered by the benefit plan, whether the services were rendered during a period the patient was covered by the benefit provider, and whether the service provider is authorized to provide services for persons covered by that benefit plan, the benefit provider will pay the health care service provider for the service provided at a specified rate. However, if any of the numerous requirements are not met, the claim of the health care service provider is not submitted or processed for payment. When such a query for eligibility status is rejected, the health care service provider can seek to recover the fees due from the patient, or from a patient&#39;s secondary benefit provider, if any exists. Often, when all other recourse has been exhausted, the service provider must absorb the loss and not receive payment for the services provided. 
     Denial of eligibility for treatment is typically because the service provider is not authorized to provide service for persons covered by a specific benefit plan, the service provided is not covered by the benefit plan of the patient, the date on which the service was provided was not a covered date, or the patient is not covered by the benefit plan. In many cases, the denial is because the information entered on the claim submitted to the benefit provider by the service provider cannot be correlated with the information in the benefit provider&#39;s database, and therefore the claim is returned as ineligible. In reality, in many of these situations, the patient/service date/service provider are eligible claims within the scope of the benefit plan, but there is a mistake or difference in the information on the claim and the information in the benefit provider&#39;s database, and so the claim is not considered eligible for reimbursement. 
     Additionally, while in many cases, a claim  100  must be submitted within a certain time period after service is rendered, if the person becomes eligible retroactively, but after the allowed time period for filing claims, a request can be made for payment for services that were rendered that would be covered by the benefit plan. Thus, it is important to make inquiries as to eligibility status at frequent intervals to determine if a person is eligible while still within the time period during which a request for payment can be made. 
     Under certain new laws and regulations, such as the Health Insurance Privacy and Portability Act (HIPPA), which regulates the insurance benefit industry, service providers are authorized to access the benefit providers&#39; databases  500 , or to enable other parties to authorize the benefit providers databases  500  on their behalf to make inquiries as to patient eligibility status. In some instances, if certain specifications are met as to the software used and other requirements, the benefit provider must make the information in their database available for such inquiries without charge. As an example, the software  10  of the present invention is fully compliant with the new laws and regulations. 
     B. OPERATION OF THE PRESENT INVENTION 
     As shown in  FIG. 1B , the software  10  of the present invention provides an analyzer  102  for converting and sorting a service provider&#39;s claims  100  and for generating a file of claims  200  in a form capable of being compared to the database of benefit providers  500  to find records  510  that match. The first step in the process encompassed by the software  10  is the generation of a file  200  containing the information from the service provider&#39;s unpaid claims  100  by the analyzer  102 . Table 1 shows an example of the fields of a claim  100 , although it should be appreciated that a variety of different numbers and arrangements of fields is possible. The exact fields  100   a  to  100   n  contained in each claim record  100  may vary, depending on what information is available in the service provider&#39;s records, and the information kept in the benefit provider&#39;s database  500 . 
     
       
         
           
               
               
               
             
               
                   
                 TABLE 1 
               
               
                   
                   
               
               
                   
                 Field 
                 Example Claim Data 
               
               
                   
                   
               
             
            
               
                   
                 Patient ID No. 
                 12345678 
               
               
                   
                 Patient Last Name 
                 Smith 
               
               
                   
                 Patient First Name 
                 John 
               
               
                   
                 Patient Middle Name 
                 Q 
               
               
                   
                 Patient Date of Birth 
                 Jan. 01, 2000 
               
               
                   
                 Patient Address 
                 123 Main St. 
               
               
                   
                 Patient City 
                 Anytown 
               
               
                   
                 Patient State 
                 Texas 
               
               
                   
                 Patient Zip Code 
                 12345 
               
               
                   
                 Patient Telephone No. 
                 (214) 867-5309 
               
               
                   
                 Benefit Plan Name 
                 Medicaid 
               
               
                   
                 Benefit Plan No. 
                 Type B 
               
               
                   
                 Insured&#39;s Name 
                 Smith, John Q 
               
               
                   
                 Date of Service 
                 Jan. 28, 2004 
               
               
                   
                 Service Code 
                 ABC1234 
               
               
                   
                 Service Description 
                 Emergency Room Visit 
               
               
                   
                 Charge Amount 
                 250.00 
               
               
                   
                 Amount Paid 
                 000.00 
               
               
                   
                 Balance Due 
                 250.00 
               
               
                   
                   
               
            
           
         
       
     
     Once the claim records  100  have been converted by the analyzer  102  to the proper format in file  200 , the software  10  employs processing queries  300 . These processing queries  300  utilize claim records  100  within file  200  as the basis of the collection of one or more queries  300 ′,  300 ″, and  300 ′″, etc. of the benefit provider&#39;s database  500 . Each claim record  100  in the file  200  will be in the same format so the information therein can be compared to the records  510  in the benefit provider&#39;s database  500 . The file  200  will be saved by the software  10  in a format that can be read and compared to the fields in the benefit provider&#39;s database  500 . 
     The queries  300  contain instructions for comparing the fields  100   a  to  100   n  in each claim  100  in the file  200  with the corresponding fields  510   a  to  510   n  in each record  510  in the benefit provider&#39;s database  500  of covered persons to determine if they contain matching information. Table 2 is an example of some of the types of queries  300  that can be executed using the software  10  of the present invention. 
     
       
         
           
               
               
             
               
                 TABLE 2 
               
               
                   
               
               
                 Name 
                 Query Description 
               
               
                   
               
             
            
               
                 MC 
                 Medicaid number only 
               
               
                 SSN 
                 Social Security number only 
               
               
                 MC SSN 
                 Medicaid &amp; Social Security 
               
               
                 MC DOB 
                 Medicaid &amp; Date of Birth 
               
               
                 MC FNLN 
                 Medicaid &amp; First name, Last name 
               
               
                 SSN DOB 
                 Social Security &amp; Date of Birth 
               
               
                 SSN FNLN 
                 Social Security &amp; First name, Last name 
               
               
                 SSN LNFNINV 
                 SSN and First, Last Name switched 
               
               
                 SSN LNMN 
                 SSN &amp; Last name, Middle name replacing First name 
               
               
                 DOB FNLN G F 
                 Date of Birth &amp; First name, Last name &amp; Gender 
               
               
                   
                 (Female) 
               
               
                 DOB FNLN G M 
                 Date of Birth &amp; First name, Last name &amp; Gender 
               
               
                   
                 (Male) 
               
               
                 SSN LN 
                 Social Security &amp; Last name 
               
               
                 SSN LNFNMIa 
                 Social Security &amp; full name, MI 
               
               
                 SSN LNFNMIb 
                 Social Security &amp; last name, first name + MI 
               
               
                 SSN LNFNMIc 
                 Social Security &amp; last name, first name + “ ” + MI 
               
               
                 SSN LNFNMId 
                 Social Security &amp; last name + MI, first name 
               
               
                 DOB FN4LN 
                 DOB &amp; first name, 1st 4 letters of last name 
               
               
                 SSN 4LN 
                 SSN &amp; 1st 4 letters of last name 
               
               
                 SSN LNFNMIe 
                 Social Security &amp; last name + MI, first name 
               
               
                 DOB LNFNMIa 
                 Date of Birth &amp; full name, MI 
               
               
                 DOB LNFNMIb 
                 Date of Birth &amp; last name, first name + MI 
               
               
                 DOB LNFNMIc 
                 Date of Birth &amp; last name, first name + “ ” + MI 
               
               
                 DOB LNFNMId 
                 Date of Birth &amp; last name + MI, first name 
               
               
                 DOB LNFNMIe 
                 Date of Birth &amp; last name + “ ” + MI, first name 
               
               
                 DOB LNFN 
                 Date of Birth &amp; last name, first name 
               
               
                 DOB LNFNINV 
                 Date of Birth &amp; last name, first name switched 
               
               
                 DOB LNMN 
                 Date of Birth &amp; last name, middle name replacing 
               
               
                   
                 first name 
               
               
                 DOB LNFNHA 
                 DOB &amp; first name, 1st half of hyphenated last name 
               
               
                 DOB LNFNHB 
                 DOB &amp; first name, 2nd half of hyphenated last name 
               
               
                 DOB LNFNHAB 
                 DOB &amp; first name, hyphen/space removed from last 
               
               
                   
                 name 
               
               
                 DOB LNFNHS 
                 DOB &amp; first name, hyphen -&gt; space in last name 
               
               
                 SSN LNFNHA 
                 SSN &amp; first name, 1st half of hyphenated last name 
               
               
                 SSN LNFNHB 
                 SSN &amp; first name, 2nd half of hyphenated last name 
               
               
                 SSN LNFNHAB 
                 SSN &amp; first name, hyphen/space removed from last 
               
               
                   
                 name 
               
               
                 SSN LNFNHS 
                 SSN &amp; first name, hyphen -&gt; space in last name 
               
               
                   
               
            
           
         
       
     
     A query  300  can ask about a variety of information in various fields  510   a - n  in the records  510  in the benefit provider&#39;s database  500 . For example, a query  300 ′ could be as simple as checking to determine if the information in the patient identification number field  100   a  of a service provider&#39;s claim record  100 ′ in the file  200  of claims matches the identification number field  510   a  in any records  510  in the benefit provider&#39;s database  500 . Or, a query  300 ″ could be more complex, and search for a variety of information matches, or partial matches, in multiple fields in the records  510  in the benefit provider&#39;s database  500 . For example, the query  300 ″ could check for claims  100  and records  510  in which both the date of birth fields  100   b ,  510   b  in the file  200  and benefit provider&#39;s database  500  match, and also the first 4 letters of the last name fields  100   c ,  510   c  match. It can be appreciated that a very large variety of queries  300  can be configured and used. The queries  300  can be virtually unlimited, as long as the information to be queried is available in the service provider&#39;s records  100  and in the benefit provider&#39;s database  500 . 
     The software  10  of the present invention performs more queries  300 , and more flexible queries of the benefit provider&#39;s database  500 , and performs comparison and analysis to determine if there is a match between a claim  100  and record in the benefit provider&#39;s database  500 , than the prior art software. In contrast, the prior art software made only limited queries, such as seeking to determine if the name, identification number and date of birth of the patient claim  100  matched a record  510  in the benefit provider&#39;s database  500 . 
     It is this expanded scope and flexibility that results in the greater number of matched records than was found with prior art software. The software  10  of the present invention, in addition to finding matching records, because it does more queries  300 , can also determine additional data about a claim  100 , such as whether or not the claimed service is covered, the balance due on a claim  100 , and even the amount of the balance due that is eligible for reimbursement. A surprising number of matches between service provider claims  100  and benefit provider databases  500  were found using the software of the present invention that were not found using prior art software. In one instance, a hospital, making just one set of queries  300 , identified several million dollars in claims that were not previously found to be eligible for reimbursement. 
     Repeated execution of the queries  300  of the same benefit provider&#39;s database  500  at regular intervals, such as monthly or bi-weekly, continued to reveal claims  100  that were not eligible for reimbursement at the time the initial queries  300  were run, but subsequently became eligible for reimbursement. It can be appreciated that if these queries  300  were not subsequently run, the claims  100  found would not be reimbursed. Additionally, because there is typically a limited time period after a patient becomes eligible for benefits in which a claim  100  can be filed, it can be appreciated that if the queries  300  are not run at regular intervals, while matches could be found, they might be found too late for the service provider to seek reimbursement. 
     Additionally, it can be appreciated that identifying claims which would qualify for reimbursement under certain government medical programs would be important, even if reimbursement were not actually received, in order to help determine qualification for other government programs, and/or whether budget and funding estimates are accurate. For example, hospitals and other service providers that provide services to a large number of patients qualifying for Medicaid and/or Medicare could receive funding from another government fund for service providers who treat a disproportionate share of low-income patients. By using the results of the queries to identify qualifying patients, even if recovery cannot be made under the initial program, the treatment can be used for reporting and submitting requests for funding under secondary programs, such as the disproportionate share programs. For example, some patients who are treated who might qualify for reimbursement under state government managed programs may be from out of state, and therefore such a claim  100  may not be entitled to reimbursement. However, such unreimbursed claims may be used to qualify the service provider for reimbursement under secondary programs. The software  10  of the present invention can be used to provide reports as to the patients treated, anticipated and projected funding, whether the service provider is treating more or less low-income patients than projected, and potential entitlement for future programs. This information is very useful to a service provider, as knowing this information can be used to project budgets, deficits and qualification for additional funding. 
     Typically, the first query  300 ′ might be to check for a person in the benefit provider&#39;s database  500  having a social security number/other unique identification number, and/or last name and first name that matches that of a patient for whom the hospital had provided services. Exactly which query  300  would be the first query  300 ′ would depend on how the benefit provider structures its database records. 
     Additionally, a query  300  can also be a series of sequential queries. For example, a query  300 ′ could be done to match the patient identification field  100   a  in a claim  100  with the patient identification field  510   a  for any matching record  510  from the benefit provider&#39;s database  500 . If the patient ID number matches, then a second query  300 ″ can be made between these matching records found in response to query  300 ′ to determine if the date on which the service was provided falls within the dates of coverage provided by the benefit provider to that patient, and only if the answer to the second query  300 ″ is also positive will the record be set aside in the file  400  for further processing. Alternatively, the system  10  could be configured so that if there is a match in the first electronic query  300 ′, the records could be flagged and set aside, and the second query  300 ″ could be done separately in a different query  300  or in or by a different system, or could even be done manually. 
     Note the software  10  can be configured so that all the queries  300  which are selected to be made could be run simultaneously or sequentially, or they could be grouped together and run sequentially. The purpose of different orders of queries or grouping of queries is to maximize efficiency of the software  10  of the present invention. The process in making such queries  300  of generally comparable records can also employ a variety of techniques, such as fuzzy and soundex searches. It should be appreciated that the queries  300  selected, the order in which they are performed, and the groupings of queries can be adapted or modified, depending on results returned from the queries  300 . 
     Once the queries  300  to be run have been selected and generated by the software  10 , the benefit provider&#39;s database  500  is accessed, and the software  10  of the present invention executes the first selected query  300 ′ thereon. If one or more matching records  510 ′ is found in the benefit provider&#39;s database  500  for a claim  100 ′, the claim  100 ′ is distinguished or flagged, removed from the file  200 , and stored separately from the remainder of the claims  100  in the service provider&#39;s database  200  in a file  400 , along with the information from matching records  510 ′ from database  500 . The purpose of removing the matched claim  100 ′ from the file  200  is to streamline efficiency of the queries  300 . Because one or more matches have already been made, there is no need to make additional queries  300  about this particular claim  100 ′. The query  300 ′ will then be performed for the next claims  100 ″ in the file  200  of service provider&#39;s claims, if any. If matches are found, then this claim  100 ″ and the matching records  510 ″ from the benefit provider&#39;s database  500  will also be stored in the file  400 . If no match is found for claim  100 ″, the claim remains in the file  200 . Query  300 ′ will be performed for each claim  100  in the file  200 . 
     If, after making the initial query  300 ′ of the benefit provider&#39;s database  500 , there are still claims  100  in the service provider&#39;s file  200  that were not correlated with records  510  in the benefit provider&#39;s database  500 , there are a variety of optional processes that could occur. No additional actions could be taken, and the claims  100  remaining in the file  200  would remain as ineligible status. 
     Alternatively, if there are additional queries  300 ″,  300 ′″, etc., that are in the selection of queries  300  to be made, the next query  300 ″ can be made of the benefit provider&#39;s database  500  to try and find additional matches with claims  100  in the service provider&#39;s claims file  200 . Again, for each claim  100  in the file  200 , query  300 ″ will be made of the benefit provider&#39;s database  500 , and if any matches is found, that claim  100 ′″ is flagged, placed in the file  400  and removed from the file  200  of unmatched claims. The software  10  then continues to make the same query  300 ″ for each remaining claim  100  in the service provider&#39;s file  200 . This cycle of querying/record flagging will continue until all claims  100  in the service provider&#39;s claims file  200  have been matched to at least a record  510  in the benefit provider&#39;s database  500 , or until all queries specified have been made of the benefit provider&#39;s database  500  for all claims  100  in the service provider&#39;s claims file  200 . 
     Once all the queries  300  of the benefit provider&#39;s database  500  have been run, the file  400  of all matched records is generated. In the file  400 , each claim  100  is associated with the related matching record  510  from the benefit provider&#39;s database  500 . For example, claim  100 ′, from the file  200  which was associated with a record  510 ′ from the benefit provider&#39;s database  500  will be grouped together in the file  400 . The file  400  can be saved on a computer, or delivered via other methods, such as via the internet, as an attachment to an e-mail, as a facsimile, or as a physical document. A report  450  of contents of the file  400  can be generated and provided to the service provider so that the eligible claims can be submitted for payment by the service provider. 
     The report  450  can be delivered to the service provider in a variety of methods, depending on their preference, including delivery by e-mail, in paper form, or by internet or a variety of other forms. Reports  450  can include a variety of information such as the information from each claim  100  in the service provider&#39;s database for which any matching record  510  in the benefit provider&#39;s database  500  was found.  FIGS. 2A ,  2 B, and  2 C show samples of some of the many reports that can be generated using the software of the present invention. 
     As can be seen in the report in  FIG. 2A , a listing is provided of claims for which a match was found in the benefit provider&#39;s database. Any information in the service provider&#39;s database that was incorrect or differed from that in the benefit provider&#39;s database is shown in different print for assistance in easily identifying the problem so the claim can be corrected. 
     As can be seen, the report  450  shown in  FIG. 2A  is organized so that the service provider can easily review the information to determine those records having errors, and exactly what the errors are, so the claims can be corrected and resubmitted. In contrast, the prior art software generated reports that simply listed names and identification numbers of patients for which a match was found in the benefit provider&#39;s database  500 . No sorting of records was done as in the reports of the present invention, and no additional information was provided from the benefit provider&#39;s database  500 , such as eligibility dates and billing deadlines, so additional manual analysis was required to determine if a claim could be submitted for payment. Additionally, because the prior art software did not do any multi-field comparisons or partial matches with analysis, records such as the first three shown in the sample report in  FIG. 2A  would not have been discovered at all. 
     A record such as the fourth record shown in the sample report in  FIG. 1A , which would have appeared as eligible for reimbursement using software of the prior art, which only checked for a match of identifying information for the patient, would have resulted in a claim that was submitted being rejected, because the service type code was entered incorrectly. Using the software  10  of the present invention, which checks to see if the service rendered is eligible for reimbursement, would find the incorrect service code, which could be corrected before the claim  100  was submitted for reimbursement. 
     The fifth record shown in the sample report in  FIG. 2A  shows a claim  100  for which partial payment has been received, but for which there is still an outstanding balance. The software of the present invention has performed analysis to determine that the patient is covered by the benefit provider, and that the service is eligible for reimbursement. Therefore, the service provider can submit the claim  100  to seek to recover the outstanding balance. The report also shows the amount of the outstanding balance that is eligible for reimbursement. In this case, it is less than the full amount because the deductible for the benefit provider has not yet been met by this patient. This claim is also an example of a claim which has become eligible for benefits since the last time a report was run, and lists the date by which any claim must be made. 
     The last entry on the sample report of  FIG. 2A  shows a claim  100  that would have been qualified for reimbursement, had it been found and submitted in a timely manner. Such results would occur if the queries  300  of the present invention were not made on a regular basis. 
       FIG. 2B  shows a pie chart break-out of an example of one instance in which the software  10  of the present invention was used showing the amount of claims eligible for reimbursement for a benefit provider, broken out by class of benefit provider the number of claims for each class, and the amount of money for the claims for each class. Additional information from the service provider&#39;s and benefit provider&#39;s records that would be useful to the service provider in submitting the claim is also provided, such as the deadline, if any, by which the claim must be submitted. 
       FIG. 2C  shows a report that provides information about claim eligibility verification for a variety of service providers, including the amounts identified for the claims, broken out for queries made on a regular basis. As can be seen, while the number for subsequent queries  300  typically decreases, it can be seen that additional eligible claims are identified when the software  10  is used to make subsequent queries  300 . 
     It should be appreciated that a variety of different reports, report formats, and information can be used, depending on the needs of the service provider. The information in the reports  450  can be used for a variety of functions, such as to track errors, and possibly reduce similar future errors made when submitting claims. Additionally, the reports  450  can be used to monitor query results to determine the effectiveness of a particular query  300 . If a particular query  300  does not ever produce any record matches, a decision could be made to not continue to make that query  300 , or to enhance it in some way so as to increase the likelihood of obtaining a match. 
     Depending on the benefit provider&#39;s system, claims for which a match was found can be filed on-line, and/or a manual submission of claims for which payment is requested can be made. 
     The software  10  can be modified continually or periodically to ensure compliance with various local, state and/or federal laws, depending on where it is used. Additionally, because the world of medical service and benefit providers is rapidly and continuously changing and evolving, the software  10  of the present invention has been designed to be flexible and adapt to ongoing changes in the industry. 
     C. EXAMPLES 
     It is appreciated that some examples may be helpful in illustrating the features of the present invention. If a service provider, such as a hospital, had a large number of claims  100  for services it had provided to patients (i.e. an emergency room visit, a hospital stay, etc.), the software  10  of the present invention could be used to inquire as to the status of the claims  100 . The software  10  would first be used to generate a file  200  in the appropriate form that contained information for each claim  100 . For purposes of this example, assume that there are 90 (ninety) claims  100  in the file  200 . 
     The software  10  would also be used to develop a series of one or more queries  300  that could be made of the benefit provider&#39;s database of members to find members of the benefit provider&#39;s plan for whom the service provider had rendered service, but has not yet been reimbursed. Again, only for purposes of this example, assume that there are 2 queries to be made against the benefit provider database  500 , sequentially, and a third query to be made for all records which were entered in file  400 . 
     Typically, the first query  300 ′ might be to check for a person in the benefit provider&#39;s database  500  having a social security nuter/other unique identification number, and/or last name and first name that matches that of a patient for whom the hospital had provided services. Exactly which query  300  would be the first query  300 ′ would depend on how the benefit provider structures its database records. 
     Such an initial standard query is useful to patients eligible for reimbursement. In some situations, there is a delay in a patient being entered into a benefit provider&#39;s database, so if the claim is submitted to the benefit provider for payment before the patient has been added to the database, the claim  100  status will be returned as ineligible. Additionally, for some medical benefit programs, such as Medicaid and the Consolidated Omnibus Budget Reconciliation Act (COBRA), coverage can be retroactive. Similarly, in these situations, the patient may not appear in the database of persons qualifying for benefits under that plan when the patient is treated, or the database may indicate that the patient was not covered on the date the service was rendered. However, if the patient is added to the benefit provider&#39;s database subsequently, the claim will only be shown as “eligible” if the claim is re-submitted after the patient is in the benefit provider&#39;s database  500 . In some instances, it has been found that several years can elapse before a claim  100  becomes eligible for reimbursement. However, in many cases, there is only a limited time allowed after a patient becomes eligible that claims  100  can be submitted to the benefit provider. Thus, queries  300  of the benefit provider&#39;s database  500  must be made on a regular basis so that eligible claims  100  can be identified in a timely manner, while the claim  100  can still be filed. 
     Another example of situations in which the patient may not appear in the benefit provider&#39;s database  500  when a claim is first submitted is for newborn babies. Such patients do not always have a unique ID number, such as a social security number, at birth. In some cases, there is even a delay in the patient being given a name, and the hospital records may simply refer to the child as “Baby Boy Smith.” Thus, the hospital may not have the proper information available to it to be able to generate a claim with information that matches the benefit provider&#39;s database  500 . Even if the hospital had the correct name or identifying information, these patients are not added to the insurer&#39;s database until after the child is born, and there is typically a delay in such information getting entered into the database. Thus, the hospital could submit a claim  100  immediately after the child is born, and there could be no related record  510  in the benefit provider&#39;s database  500  at that time. Thus, these claims  100  are often not paid because they cannot, be matched up with a patient in the benefit provider&#39;s database  500 . Again, making eligibility inquiries of the benefit provider&#39;s database on a regular basis will reveal that the patient has been added to the database  500  and the claim  100  is eligible for reimbursement. 
     Another example of claims  100  that this query  300 ′ might find a match for would be an instance where the benefit provider matches records by patient name, rather than patient identification, and the benefit provider has a patient in its database  500  as John Smith, but the service provider submitted a claim for service provided to John Smithe. Because the benefit provider did not find John Smithe in its database, it originally rejected the claim as ineligible; however, because the patient IDs match, this query would make a match. 
     Once the queries  300  have been selected, the software  10  can be configured to run the selected queries  300  against the benefit provider&#39;s database  500  to find records that match any of the claims  100  in the file of the service provider&#39;s unpaid claims  200 . Again, for purposes of this example, assume that the first query  300 ′ is to find an exact match between the patient ID fields of any claim  100  in the file of the hospital&#39;s claims  200 , and any patient record  510  in the benefit provider&#39;s database  500 . Assume that when query  300 ′ has been run, and the data in each of the ninety claims  100  in the service provider&#39;s file  200  has been compared to the records  510  in the benefit provider&#39;s database  500 , twenty of the claims  100  are found to have matching records  510  in the benefit provider&#39;s database, therefore being eligible for reimbursement. When a match is found for a claim  100 ′ in the benefit provider&#39;s database, that claim  100 ′ and the information from the matching record  510 ′ in the benefit provider&#39;s database  500  is placed in a file  400 . Each claim  100  which has been matched to a record  510  from the benefit provider&#39;s database  500  is removed from the file  200  after query  300 ′ has been run and completed. Thus, after the first query  300 ′ has been run, only seventy claims  100  will remain in the file  200 . 
     For purposes of this example, assume the second query  300 ″ is a query to find claims  100  in the seventy remaining claims in the file  200  for which the date of birth field is the same as the date of birth field in a record  510  in the benefit provider&#39;s database  500 , the first name fields are the same, and the first four letters of the last name field are the same. This query would find patients for whom the patient ID was entered incorrectly, but the name and date of birth information was correct. Thus, if for patient Thomas Jones, his ID number was incorrectly entered in the service provider&#39;s claim as 12345679, but the actual ID number was 12345678, the first query  300 ′ would not find a matching record  510  in the benefit provider&#39;s database  500 . However, the second query  300 ″ would find a matching record  510 . 
     After the first query  300 ′ has been run, the second query  300 ″ is run for the remaining seventy claims  100  in the file  200 . Assume this query results in another twenty claims  100  being matched with one or more records  510  in the benefit provider&#39;s database  500 . Each of these twenty claims is also removed from file  200  and placed in file  400 , leaving only fifty claims  100  in the file  200 . It can be appreciated that with queries  300 ″ such as this, multiple matches could be found with persons having the same date of birth, first name, and last four digits of the last name, and therefore, multiple records  510  could be returned that potentially match a claim  100 . 
     When all the queries  300  have been run, the software  10  will exit the query of the benefit provider&#39;s database  500 , and a file  400  of all matched records is generated. In the case of this example, file  400  contains forty claims  100  for which one or more matches has been made in the benefit provider&#39;s database  500 . The file  400  contains the information from each claim  100  for which a matching record  510  in the benefit provider&#39;s database  500  was found, and the information from the matching record(s)  510  in the benefit provider&#39;s database. A report  450  of contents of the file  400  can be generated and provided to the service provider so that the matched claims can be submitted to the benefit provider. 
     However, in the case of this example, the software runs a query  300 ′″ on all forty records in the file  400  to determine if the date by which a claim must be submitted for reimbursement is later than the present date. If not, that claim could be flagged in the file  400  as being a past deadline claim. Or, it could be a query that would check for additional matching fields between claims  100  that have generated more than one matching record  510  from the benefit provider&#39;s database  500 . It can be appreciated that this query could have been made as part of the first or second queries  300 ′,  300 ″ of the benefit provider&#39;s database  500 , or as a separate query  300  of the benefit provider&#39;s database  500 . However, again, only for the purposes of this example, assume that it was found to be much more efficient to make this date query  300 ′″ after file  400  had been generated, rather than as a query to the benefit provider&#39;s database  500 . Additionally, such information about claims qualifying for payment could be important for tracking whether a health care service provider qualifies for reimbursement from other programs, such as disproportionate share Medicaid or Medicare reimbursement funds, as discussed above. If this query was performed before the claim  100  was placed in the file  400 , the claim  100  might not be placed in the file  400 , and therefore it could be difficult to track this type of information when preparing reports to determine qualification for the additional programs. Alternatively, it can be appreciated that further inquiries such as this could be made manually upon review of the report  450  of matching files  400 . Again, how such analysis is performed depends on the specific needs of a user. 
     If appropriate, additional analysis can be made of the service provider&#39;s claims  100  and any matching records  510  from the benefit provider&#39;s database  500  to determine if there are additional fields that match between the record in the benefit provider&#39;s database and the claim to ensure the patient is the same entity. For example, if multiple records  510  are returned that same date of birth, first name, and first 4 digits of the last name, additional analysis can be done to look for additional matches in other fields, or determine the probability that a specific record  510  matches a specific claim  100 ′. 
     In one arrangement of the present invention, queries  300  can be run of the benefit provider&#39;s database  500 , with charges being incurred on a per query basis, as per the prior art software. In another arrangement of the present invention, because the software  10  of the present invention complies with the requirements of the new laws governing such queries  300 , the queries  300  can be run without charge for the number of queries run, or the number of times queries are run. If the queries  300  are made by a third party on behalf of the service provider, payment to the third party can be made based on the number of claims  100  that are matched to database records  510 , and for which payment is received by the service provider. 
     It is understood that the present invention can take many forms and embodiments. Accordingly, several variations may be made in the foregoing without departing from the spirit or the scope of the invention. Having thus described the present invention by reference to certain of its preferred embodiments, it is noted that the embodiments disclosed are illustrative rather than limiting in nature and that a wide range of variations, modifications, changes, and substitutions are contemplated in the foregoing disclosure and, in some instances, some features of the present invention may be employed without a corresponding use of the other features. Many such variations and modifications may be considered obvious and desirable by those skilled in the art based upon a review of the foregoing description of preferred embodiments. Accordingly, it is appropriate that the appended claims be construed broadly and in a manner consistent with the scope of the invention.