Abstract:
A method for automatically determining the expected cost for a medical visit includes entering patient identification information ( 30 ); accessing the patient&#39;s medical records; entering a reason for the patient&#39;s visit ( 35 ), identifying the patient&#39;s health-care plan ( 50 ); and calculating an expected cost and payment for the medical visit.

Description:
FIELD OF THE INVENTION  
       [0001]     This invention relates in general to medical information systems, and in particular to systems for clinics and doctor&#39;s offices.  
       BACKGROUND OF THE INVENTION  
       [0002]     In a doctor&#39;s office or a medical clinic, there is a need to gather patient information or update the information periodically. It is also desirable to obtain information on the method of payment that the patient will use. Often, presenting a card identifying the patient&#39;s insurer does this. Less often, the insurer is called to confirm the coverage.  
         [0003]     The patient knows what his or her medical symptoms are but is less sure of costs related to curing his or her condition. The course of treatment is up to the doctor, but there is a need, from the patient&#39;s perspective, to understand what will be covered by insurance and what will be paid for out-of-pocket. Recent changes in insurance coverage and legislative modifications make this more and more difficult for the patient to make properly informed decisions. For those who have no medical coverage, the information on costs may by even more important.  
         [0004]     Informational kiosks exist today (www.galvanon.com) that collect patient information at a hospital, clinic or office. These systems may link this information with practice management software (PMS) and electronic medical records (EMR). The insurers, like Blue Cross/Blue Shield, also have systems that allow doctor&#39;s to access their system for information about their patients, with the patient&#39;s permission. An example is shown in the following URL: (https://www.excellusbcbs.com/providers/index.shtml). Methods for identify checking of a patient are also well known in the art and include methods such as records with bar codes, multiple question/answer sequences, user name/password pairs, patient ID bracelets, RFID tags placed on the patient, etc.  
         [0005]     There is an unmet need, however, to provide doctors and patients with a quick, automated, estimate of financial information—patient cost, provider payment, concerning a patient visit or procedure. This estimate may be based on a variety of information on different servers or websites.  
       SUMMARY OF THE INVENTION  
       [0006]     Briefly, according to one aspect of the present invention a method for automatically determining the expected cost for a medical visit comprises: entering patient identification information; accessing the patient&#39;s medical records; entering a reason for the patient&#39;s visit, identifying the patient&#39;s health-care plan; and calculating an expected cost and payment for the medical visit.  
         [0007]     The present invention is intended to provide the patient with a first and last contact point for a visit to a primary care physician (PCP) office or clinic. In addition, the invention estimates the payment that will be required as a result of this visit, relative to their coverage and out-of-pocket expenses.  
         [0008]     The present invention is intended to be easily adaptable to the office/clinic where it is used, without requiring the intervention of highly trained and experienced staff for extended periods of time, by integrating with the existing PMS in the office or clinic. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0009]      FIG. 1  is a flow diagram of the process the patient goes through in the office/clinic.  
         [0010]      FIG. 2  is a representation of the patient demographic information, available to the office/clinic.  
         [0011]      FIG. 3   a  is a representation of the billing and privacy statement.  
         [0012]      FIG. 3   b  is a representation of a Health Insurance Portability and Accountability Act (HIPAA) privacy statement.  
         [0013]      FIG. 4  is a flow chart, describing the validation of a patient&#39;s coverage by a health care payer.  
         [0014]      FIG. 5  is a flow chart, showing possible billing relationships between the office/clinic and health care payers.  
         [0015]      FIG. 6  is a flow chart, showing the patient process for creating and updating paper based medical records.  
         [0016]      FIG. 7  is a flow chart, showing the patient process for creating and updating electronic medical records.  
         [0017]      FIG. 8  is a flow chart, showing the process for estimating a charge set.  
         [0018]      FIG. 9  is a representation of a billing summary available at patient check-out. 
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0019]     The present invention will be directed in particular to a system for entering, modifying, and interpreting information from several sources to optimize business elements of a doctor&#39;s office of clinical check-in/check-out system. It is to be understood that elements not specifically shown or described may take various forms well known to those skilled in the art.  
         [0020]     The system is intended to provide the patient with a first and last contact point for a visit to a PCP office or clinic. At check-in, the patient interacts with the system to establish identity, update/validate insurance information, patient demographic information, medical history, and purpose of visit. At this point, the system estimates the payment that the patient will be required to make.  
         [0021]     The system is intended to be easily adaptable to the office/clinic where it is used, without requiring the intervention of highly trained and experienced staff for extended periods of time. Integration with any PMS is accomplished by means of creating a standard interface specifying a standard interface to the PMS, and creating custom code as required to access the PMS.  
         [0022]     Referring now to  FIG. 1 , a flow diagram of the process the patient goes through in the office/clinic:  
         [0023]     Patient identity establishment, at patient arrival  10 , is the responsibility of the office/clinic. The check-in (kiosk)  15  assists in this identification  30  by allowing for the use of bar coded or magnetic stripe card or smart card media (or more, jump drive, web links, eye scan, etc.), to be created and/or supplied by the office/clinic, and used as an access control mechanism to the system. Examples are well known in the industry: (http://www.freescale.com/webapp/sps/site/application.jsp?nodeId=02430ZnQXG XDWd).  
         [0024]     In addition to the information from those media, additional data entry and verification is required to establish reasonable identification (e.g. patient date of birth). Once the system accepts the verification sequence, the patient is allowed further into the system workflow process. Identity checks, as appropriate, are maintained throughout the balance of the flow. These are required because the patient, and so the check-in system, may access multiple different computer systems for relevant information, depending on the office/clinic computer system configuration and service provision.  
         [0025]     Within the scope of the office/clinic, there is demographic information associated with the patient, including but not limited to, home address, phone number and other contact information. The demographic information is retained in the office/clinic PMS  12 . That demographic information is subject to change from time to time.  
         [0026]     Referring to  FIG. 2 , the system provides the patient with the opportunity to review and update that demographic  40 , by retrieving it from the PMS, providing a data entry/edit user interface  70 , and placing it back into the office/clinic PMS. Methods to automatically assist in this data placement are well known. An example can be found at www.Google.com where auto fill can be used in web-based applications.  
         [0027]     Generally, prior to the start of this process, the patient has made an appointment at the office/clinic, usually thru the office/clinic staff, providing some purpose of the visit  35 . Should the appointment not have been made, or the reason not been recorded, the system responds appropriately by proceeding thru the sequence of questions/answers to create the appointment, and inquire as to the purpose of the visit.  
         [0028]     Referring to  FIG. 3   a , billing and privacy  75  agreements are presented to the patient. The patient is given the opportunity to read and acknowledge the terms and conditions.  
         [0029]     Referring to  FIG. 3   b , HIPAA Compliance for privacy practices  80  is provided through the system, by means of an interface allowing for an electronic signature and screens  70  requesting appropriate allowances.  
         [0030]     The system requires the patient to validate appropriate services rendered payment capability, usually through health care insurance  50  coverage and an on-site co-pay. Referring to  FIG. 4 , this is accomplished by having the patient  100  identify  170  his/herself to the appropriate health care payer organization, and specify the patient coverage identifier  180  with the health care payer  120 . The same mechanisms as used for patient identification can be used here, to establish identity to the health care payer organization, as well as to specify contract/coverage information. Identity validation  140  may be different from that used initially, because there is no possibility of getting all cooperating/health care paying systems to presume the same patient validation method.  
         [0031]     The patient information is communicated to the health care payer  120  via computer systems connected by a network or Internet  110  connection.  
         [0032]     Referring to  FIG. 8 , the purpose of the visit  500  corresponds to one or more procedures to be performed, which in turn correspond to one or more current procedure terminology (CPT) codes  510 . The CPT codes are shorthand for a sequence of medical procedures, and as such, represent billable ‘units’ to health care payers. In actual practice, prices for medical procedures are loosely based, in the United States, on Medicare published rates. Health care payers base their re-imbursement rates on differences from Medicare rates. Each health care payer has the possibility of having different rates. Additionally, as health care payers offer coverage contracts to health care buyers (either to group buyers (e.g. employers), or individual consumers), those coverage contracts may have different characteristics. Examples of differences among coverage plans include co-pay and reimbursement amounts, payment limit caps, and alternative forms of patient payments.  
         [0033]     Those codes are translatable into financial characteristics, specific to health care payers and their contracts/coverages, including but not limited to: patient co-pay  150 , prospective payment to office/clinic  140  to office/clinic, and any constraints on reimbursement.  
         [0034]     One purpose of the system is to provide the patient with information regarding the expected cost to the patient of the upcoming procedures, and to provide the office/clinic staff with information regarding the patient payment mechanism.  
         [0035]     The office/clinic  200  will generally, but not always, have billing relationships with more than one health care payer  215 ,  218 , each of which will offer one or more coverage plans  220 . This relationship is shown in  FIG. 5 . After determining the appropriate health care payer, the computer system in the office/clinic will communicate with the health care payer  590 , sending  205  the patient identification, coverage ID and purpose of visit, in the manner the health care payer system expects, which yields returning information  210  concerning patient co-pay, prospective payment to office/clinic, and any constraints on reimbursement.  
         [0036]     The office/clinic will make the decision to accept the health care payer payment  520 . In the case where the office/clinic will bill the health care payer  280 ,  530 , the office/clinic will accept the co-pay  265  from the patient, and subsequently bill the health care payer  270 .  
         [0037]     Some offices/clinics may refuse to bill health care payers  525 , not accept health care payer payment  260 , and require direct patient payment  285 . The office/clinic will have a pricing list that details the charges to be made for the CPT codes that correspond to the visit. The system will use that pricing list to translate CPT codes to charges  570  for the visit. In this case, the office/clinic will bill the patient  275  the amount due. Information about health care payer coverage is still of value to the practice, for the purposes of: establishing an understanding of community pricing levels; determining areas where premium pricing over community levels may be justified; demonstrating the economic viability of the office/clinic to external parties. It is of course possible that offices/clinics that do not have billing/paying relationships with specific health care payers will not be allowed access to that specific information.  
         [0038]     Regardless of the sources of information, there is sufficient data present to build up patient expected charges  580 , and present the expected costs of the visit.  
         [0039]     Referring to  FIG. 6 , many offices/clinics maintain paper medical records (MR)  300  for their patients. New patients  340  will be required to fill out forms  310  on paper. The typical patient  350  will be asked to review printed, existing information, and fill out update forms  315 . In either case, the new or updated paper forms will be reviewed during the encounter with medical personnel  320 . After the encounter, the forms will be placed into a paper file (‘the chart’)  330 .  
         [0040]     Referring to  FIG. 7 , some offices/clinics maintain electronic medical records (EMR)  45 ,  400  for each patient, using local systems  412 , remote systems  414 , or a hybrid of both  410 . Over time, more remote EMR systems will be in use, allowing the system to provide increasing utility to the patient. New patients  340  will be required to populate their EMR via computer data entry  420 , while the typical patient  350  will review existing information, and perform a computer data update  440 . The system provides the typical patient with a view of the current EMR, for the purposes of review/validation, as well as thought provocation prior to the procedure. Review/validation is useful for patients with multiple offices/clinics to visit, as well as providing reminders for office/clinic staff interactions. There will be a review of the data during the encounter  430 . During or after the encounter, the medical staff will update the information in the EMR as appropriate.  
         [0041]     After check-in, the patient proceeds with the encounter  20 , and participates in the procedures/tests/purposes of the visit. There is always the possibility that the initially provided visit reason does not describe the actual encounter, or additional procedures were performed, or other non-anticipated activity took place, which will impact the cost to the patient and/or payments to the office/clinic. The staff of the office/clinic must assure that the system has access to the actual procedures which took place, in order to assure that cost and billing information is available to the patient prior to leaving the office/clinic.  
         [0042]     At check-out  25 , the patients is enabled to view the actual charges  55  relevant to the visit  600 , shown in  FIG. 9 , review any current or new information in their medical history  60 , and create a personal health record (PHR)  65  for their personal use.  
         [0043]     The invention has been described in detail with particular reference to certain preferred embodiments thereof, but it will be understood that variations and modifications can be effected within the scope of the invention.  
       PARTS LIST  
       [0000]    
       
           10  patient arrival at doctor&#39;s office  
           12  practice management system (PMS)  
           15  check in at kiosk  
           20  encounter with doctor  
           25  check-out from office  
           30  patient identification  
           35  purpose of patient visit  
           40  patient demographics  
           45  patient medical history  
           50  patient insurance  
           55  actual charges for visit  
           60  medical history update  
           65  personal health record  
           70  sample patient demographics screen  
           75  sample billing and privacy screen  
           80  sample HIPAA notice of privacy practices screen  
           100  patient  
           110  network or Internet  
           120  healthcare payer  
           130  validation from healthcare payer  
           140  healthcare payer payment to office/clinic  
           150  patient co-pay  
           170  patient identification  
           180  patient coverage ID  
           200  office/clinic  
           205  patient identification, coverage ID and current procedural terminology (CPT)  
           210  payment information from healthcare provider  
           215  healthcare payer #1  
           218  healthcare payer #n  
           220  coverage plan 1, 2, 3, n  
           260  choice on acceptance of healthcare payment  
           265  acceptance of co-pay  
           270  billing of healthcare payer  
           275  bill payment by patient  
           280  healthcare coverage is accepted  
           285  healthcare coverage is refused  
           300  paper medical record (MR)  
           310  fill out paper forms  
           315  fill out update paper forms  
           320  review of paper forms during visit  
           330  file paper forms after visit  
           340  new patient  
           350  typical patient  
           400  electronic medical record (EMR)  
           410  EMR data sets  
           412  internal EMR data set  
           414  external EMR data sets  
           420  computer data entry  
           430  review of data during visit  
           440  computer data updates  
           500  select a purpose of the visit  
           510  translate purpose of the visit into CPT(s)  
           520  office/clinic accept health care payer payment  
           530  yes, accept HCP payment  
           560  no, do not accept HCP payment  
           570  translate CPT(s) into charges  
           580  build up patient expected charges  
           590  communicate to health care payer  
           600  screen representation billing summary