Great research starts with great data.

Learn More
More >
Patent Analysis of

Method for detecting and preventing fraudulent healthcare claims

Updated Time 12 June 2019

Patent Registration Data

Publication Number

US10002391

Application Number

US13/270255

Application Date

11 October 2011

Publication Date

19 June 2018

Current Assignee

PIONETECHS, INC.

Original Assignee (Applicant)

KUSENS, BRUCE HOWARD

International Classification

G06Q40/08

Cooperative Classification

G06Q40/08

Inventor

KUSENS, BRUCE HOWARD

Patent Images

This patent contains figures and images illustrating the invention and its embodiment.

US10002391 Method detecting preventing 1 US10002391 Method detecting preventing 2
See all images <>

Abstract

A computer implement method that assist healthcare payers in identifying potentially fraudulent claims and which requests confirmation preferably from a healthcare provider or patient of services rendered by the healthcare provider or products received by the patient. Confirmation of equipment and services can occur at different times in the settlement process including, but not limited to, prior to payments being made to health care providers.

Read more

Claims

1. A computer implemented method for automatically detecting whether a healthcare claim is fraudulent after the healthcare claim has been electronically submitted for payment, the method comprising:(a) receiving an electronic healthcare claim for payment from a healthcare provider by a healthcare claim integrity computer system of a healthcare payer, the healthcare claim integrity computer system including an analytics engine in electronic communication with an electronic data warehouse, the analytics engine programmed to determine the likelihood of potential fraud and abuse for a submitted healthcare claim and is programmed to consider data points from the submitted healthcare claim in future potential fraud and abuse determinations by the analytics engine;(b) importing electronic healthcare claim data from the received electronic healthcare claim into the analytics engine, said healthcare claim data identifying one or more services provided to a patient or one or more products received by a patient from the healthcare provider;(c) electronically determining by the analytics engine based on programmed detection criteria and the imported electronic healthcare claim data whether or not the received a healthcare claim is suspect or fraudulent;(d) automatically diverting for confirmation by the healthcare claim integrity computer system any received healthcare claim determined to be suspect or fraudulent by the analytics engine in step (c);(e) for healthcare claims diverted in step (d) electronically contacting the healthcare provider or the patient who received the one or more services or products through an automated system of the healthcare claim integrity computer system;(f) electronically determining by the healthcare claim integrity computer system whether one or more services or products listed in the healthcare claim were actually provided by the healthcare provider;(g) requesting, by the healthcare claim integrity computer system, electronic confirmation from the healthcare provider or patient contacted in step (e) as to whether the one or more services or products listed in the healthcare claim were received; and(h) (i) automatically initiating an electronic intercept of the healthcare claim by the analytics engine for further investigation of the healthcare claim where the healthcare provider or patient fails to confirm that one or more services or products were received after a certain period of time; or (ii) electronically receiving, by the healthcare claim integrity computer system, a positive electronic acknowledgment from the healthcare provider or patient confirming that the one or more services or products were received and updating an electronic data warehouse that the healthcare claim was reviewed;(i) automatically updating the programmed detection criteria used by the analytics engine when reviewing future healthcare claims by the healthcare claim integrity computer system based on data points from the submitted healthcare claim and data saved concerning confirmation of the submitted healthcare claim or an intercept of the submitted healthcare claim; and(j) updating an electronic data warehouse by the healthcare claim integrity system indicating that the healthcare claim is not suspect or fraudulent for a healthcare claim receiving a positive acknowledgment in step (h)(ii) or that a claim intercept was initiated in step (h)(i).

2. The computer implemented method of claim 1 wherein said step of contacting a healthcare provider or patient comprises automatically contacting the healthcare provider or patient through phone, email, SMS or instant messaging.

Read more

Claim Tree

  • 1
    1. A computer implemented method for automatically detecting whether a healthcare claim is fraudulent after the healthcare claim has been electronically submitted for payment, the method comprising:
    • (a) receiving an electronic healthcare claim for payment from a healthcare provider by a healthcare claim integrity computer system of a healthcare payer, the healthcare claim integrity computer system including an analytics engine in electronic communication with an electronic data warehouse, the analytics engine programmed to determine the likelihood of potential fraud and abuse for a submitted healthcare claim and is programmed to consider data points from the submitted healthcare claim in future potential fraud and abuse determinations by the analytics engine;
    • (b) importing electronic healthcare claim data from the received electronic healthcare claim into the analytics engine, said healthcare claim data identifying one or more services provided to a patient or one or more products received by a patient from the healthcare provider;
    • (c) electronically determining by the analytics engine based on programmed detection criteria and the imported electronic healthcare claim data whether or not the received a healthcare claim is suspect or fraudulent;
    • (d) automatically diverting for confirmation by the healthcare claim integrity computer system any received healthcare claim determined to be suspect or fraudulent by the analytics engine in step (c);
    • (e) for healthcare claims diverted in step (d) electronically contacting the healthcare provider or the patient who received the one or more services or products through an automated system of the healthcare claim integrity computer system;
    • (f) electronically determining by the healthcare claim integrity computer system whether one or more services or products listed in the healthcare claim were actually provided by the healthcare provider;
    • (g) requesting, by the healthcare claim integrity computer system, electronic confirmation from the healthcare provider or patient contacted in step (e) as to whether the one or more services or products listed in the healthcare claim were received; and
    • (h)
    • (i) automatically initiating an electronic intercept of the healthcare claim by the analytics engine for further investigation of the healthcare claim where the healthcare provider or patient fails to confirm that one or more services or products were received after a certain period of time; or (ii) electronically receiving, by the healthcare claim integrity computer system, a positive electronic acknowledgment from the healthcare provider or patient confirming that the one or more services or products were received and updating an electronic data warehouse that the healthcare claim was reviewed;(i) automatically updating the programmed detection criteria used by the analytics engine when reviewing future healthcare claims by the healthcare claim integrity computer system based on data points from the submitted healthcare claim and data saved concerning confirmation of the submitted healthcare claim or an intercept of the submitted healthcare claim; and
    • (j) updating an electronic data warehouse by the healthcare claim integrity system indicating that the healthcare claim is not suspect or fraudulent for a healthcare claim receiving a positive acknowledgment in step (h)(ii) or that a claim intercept was initiated in step (h)(i).
    • 2. The computer implemented method of claim 1 wherein
      • said step of contacting a healthcare provider or patient comprises
See all independent claims <>

Description

I. FIELD OF THE INVENTION

The present invention relates generally to healthcare claims and more particularly to a method for helping to detect and reduce fraudulent healthcare claims.

2. BACKGROUND OF THE INVENTION

In the current environment, healthcare spending accounts for over 15% of the GDP according to a 2004 General Accounting Office report to Congress. Of the funds expended for health care each year, the National Health Care Anti-fraud Association (NHCAA) estimated that at least 3% was lost to fraud. This amounts to in excess of $60 Billion lost to fraud each year.

Health Care fraud can manifest itself in a variety of ways. Providers can bill for services or equipment not provided, administering tests that are not medically necessary, administering more expensive tests and equipment (up-coding), multiple billing for services or unbundling of lab tests performed together among others. There are even instances of policy holders letting others use their health care cards to receive improper benefits as well as instances of medical identity theft that contribute to the ongoing health care fraud problem.

The present invention is directed to a novel method for helping to detect and reduce fraudulent healthcare claims.

SUMMARY OF THE INVENTION

The present invention generally describes a novel method that assist healthcare payers in identifying potentially fraudulent claims and in confirming receipt of equipment and services at different times in the settlement process including, but not limited to, prior to payments being made to health care providers. In connection with the description of the present the following definitions will be used:


Definitions
Health
A method, process and/or system to analyze health care
Care Claim
claims and/or remittance data for the purposes of helping
Integrity
in the detection of potential fraud and abuse. It
System
additionally can include a process to verify services and
supplies provided with or by the healthcare provider
and/or patient.
835
A HIPAA compliant electronic data format utilized for the
purposes of remitting payments to healthcare providers for
services rendered. However, this format is not considered
limiting and other HIPAA or non-HIPAA compliant
electronic data formats can be used and are considered
within the scope of the invention.
837
A HIPAA compliant electronic data format utilized for the
purposes of billing payers for healthcare services rendered
to its members. However, this format is not considered
limiting and other HIPAA or non-HIPAA compliant
electronic data formats can be used and are considered
within the scope of the invention.
Analytics
A proprietary system designed to process 835 and/or 837
Engine
files or other file formats and determine the likelihood
of potential fraud and abuse based on analytical data and
rules including self “learning” algorithms. This rules
engine is preferably where the determination of a
likelihood of a fraudulent claim and/or abusive claim
is made. Preferably, a base set of rules are provided
with the system dynamically creating new rules as more
data is introduced into the system. The engine can also
take into account new claims information for
statistical analysis, responses received from
patients/providers to claim inquiries, and other data
obtained through the system over time.
1010 Data
A proprietary electronic database system utilized by the
Warehouse
Health Care Claim Integrity System to store and
process health care claim data and confirmation records.
Though not limiting, it is preferred that the database
system be relatively large and permit the use of extremely
large data sets and also that it can perform queries
across these extremely large data sets almost instantly.
Detection
A set of rules determined through analytical analysis of
Criteria
data that is utilized to determine if a claim for health
care service is potentially fraudulent. Criteria includes
but is not limited to excessive billing amounts, higher
costs per patient, excessive patients per physician,
increased number of tests per patient, abnormal
distance between treatment location and patient's
residence and a higher rate of prescription for certain
drugs. Detection Criteria also includes the creation
of rules as a result of self “learned” algorithms.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 is a flow diagram of the health care claim integrity system detection process in accordance with the present invention; and

FIG. 2 is a flow diagram of the health care claim confirmation process in accordance with the present invention.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 shows a preferred workflow for importation, analysis, confirmation and intercept of potentially fraudulent health care claims in accordance with the present invention. At step F1a healthcare claim data from an 835 Remittance Advice, 837 Claim File or other HIPAA or non-HIPAA compliant electronic data format can be imported into the analytics engine. At step F1b, utilizing proprietary rules and technology, the analytics engine makes a determination as to whether a claim is suspected of potential fraud and/or abuse and to divert suspect claims identified by the analytics engine for confirmation.

At step F1c for claims meeting the criteria and requiring confirmation of services provided and/or products received, the health care provider and/or the patient is contacted preferably, though not limiting, through an automated system via phone, email and/or SMS messaging to confirm that services or products were provided or received. Other messaging systems can also be used, such as, but not limited to, instant messaging, Facebook messaging, etc. and all are considered within the scope of the invention. Depending on the specific circumstances, confirmation may be required by the health care provider only, by the patient only, or by both the health care provider and patient.

As seen in step F1d for claims not meeting the criteria and thus not requiring confirmation of services provided and/or products received, the claim record is updated in the electronic data warehouse to reflect such and that the claim was reviewed. As seen in step F1e for claims identified in F1b (meeting the criteria as potentially suspect or fraudulent and needing further review) where the patient or provider did not acknowledge the patient's receipt of services and/or products, the claims intercept process is initiated which could either prevent the claim from being paid to the provider without further review and/or serve as an additional data point along with other factors to identify suspect claims, providers, physicians and/or patients involved in schemes involving collusion among them.

As seen in step F1f for claims identified in F1b where the patient or provider provided a positive acknowledgement for the patient's receipt of services and/or products, the claim record is updated in the electronic data warehouse to reflect such and that claim has been reviewed. This data point is then considered by the analytics engine for future claims processed by it. The invention can specifically include, but is not limited to, “seeding” confirmation messages sent to different parties involved in the transaction. Seeding in this context means intentionally introducing requests for confirmation of services or products that were not in fact received from or provided by the provider. Responses to these “seeded” requests for confirmation are used by the analytics engine to determine if collusion is involved.

FIG. 2 shows the workflow for confirming the patient's receipt of services and/or products with the confirmation coming from a patient and/or physician and also illustrates where this workflow is performed in relationship to the various steps shown in FIG. 1 (which is also reproduced in smaller size in FIG. 2). In step F1a of FIG. 2 for claims meeting criteria and requiring confirmation of services and/or products, the health care claim integrity system contacts the provider and/or the patient preferably, though not limiting, through an automated system via phone (i.e. any type of phone—cellular phone, landline, satellite phone, etc.), email and/or SMS messaging to confirm that services and/or products were provided or received. Non-limiting examples of the type of message that can be sent to the provider and/or patient are illustrated. Other messages can also be sent and are considered within the scope of the invention.

At step F1b of FIG. 2 the patients and/or providers must either enter a specific character or click on the appropriate hyperlink to indicate their response. For a non-limiting example, the patient or provider may press the “1” button on his or her phone for a “yes” response or press the “2” button for a “no” response. Other configurations, messages, phrases and numbers can be used and all are considered within the scope of the invention. Responses are received by the health care claim integrity system and utilized to update claim records.

The health care claim integrity system and method described above can provide administrative, clinical and/or financial benefits to healthcare payers, providers and patients alike, including, but not limited to, the following public benefits:

  • 1. Reduce the incident of health care fraud and abuse, resulting in significant cost savings to the payer, provider and patient.
  • 2. Reduce manual effort involved in identification of potentially fraudulent and abusive charges
  • 3. Reduce manual effort involved in the confirmation of receipt of medical services and supplies.
  • 4. Lower administrative costs due to false claims
  • 5. Minimize false medical data reported on a patient's health care record

Any computer/server/electronic database system (collectively “Computer System”) capable of being programmed with the specific steps of the present invention can be used and is considered within the scope of the invention. Once programmed such Computer System can preferably be considered a special purpose computer limited to the use of two or more of the above particularly described combination of steps (programmed instructions) performing two or more of the above particularly described combination of functions

All amounts, component or part locations, configurations, values, percentages, materials, orientations, etc. discussed above or shown in the drawings, if any, are merely by way of example and are not considered limiting and other amounts, component or part locations, configurations, value, percentages, materials, orientations etc. can be chosen and used and all arc considered within the scope of the invention.

Unless feature(s), part(s), component(s), characteristic(s) or function(s) described in the specification or shown in the drawings for a claim element, claim step or claim term specifically appear in the claim with the claim element, claim step or claim term, then the inventor docs not consider such feature(s), part(s), component(s), characteristic(s) or function(s) to be included for the claim element, claim step or claim term in the claim when and if the claim element, claim step or claim term is interpreted or construed. Similarly, with respect to any “means for” elements in the claims, the inventor considers such language to require only the minimal amount of features, components, steps, or parts from the specification to achieve the function of the “means for” language and not all of the features, components, steps or parts describe in the specification that arc related to the function of the “means for” language.

While the invention has been described and disclosed in certain terms and has disclosed certain embodiments or modifications, persons skilled in the art who have acquainted themselves with the invention, will appreciate that it is not necessarily limited by such terms, nor to the specific embodiments and modification disclosed herein. Thus, a wide variety of alternatives, suggested by the teachings herein, can be practiced without departing from the spirit of the invention, and rights to such alternatives are particularly reserved and considered within the scope of the invention.

Read more
PatSnap Solutions

Great research starts with great data.

Use the most comprehensive innovation intelligence platform to maximise ROI on research.

Learn More

Patent Valuation

$

Reveal the value <>

38.0/100 Score

Market Attractiveness

It shows from an IP point of view how many competitors are active and innovations are made in the different technical fields of the company. On a company level, the market attractiveness is often also an indicator of how diversified a company is. Here we look into the commercial relevance of the market.

33.0/100 Score

Market Coverage

It shows the sizes of the market that is covered with the IP and in how many countries the IP guarantees protection. It reflects a market size that is potentially addressable with the invented technology/formulation with a legal protection which also includes a freedom to operate. Here we look into the size of the impacted market.

74.0/100 Score

Technology Quality

It shows the degree of innovation that can be derived from a company’s IP. Here we look into ease of detection, ability to design around and significance of the patented feature to the product/service.

34.0/100 Score

Assignee Score

It takes the R&D behavior of the company itself into account that results in IP. During the invention phase, larger companies are considered to assign a higher R&D budget on a certain technology field, these companies have a better influence on their market, on what is marketable and what might lead to a standard.

16.0/100 Score

Legal Score

It shows the legal strength of IP in terms of its degree of protecting effect. Here we look into claim scope, claim breadth, claim quality, stability and priority.

Citation

Patents Cited in This Cited by
Title Current Assignee Application Date Publication Date
System and method for implementing healthcare fraud countermeasures BIOMETRIC TECHNOLOGIES, INC. 22 January 2003 22 July 2004
System and method for secure highway for real-time preadjudication and payment of medical claims MDWERKS, INC 15 April 2002 07 August 2003
Systems and methods for identifying fraud and abuse in prescription claims NDCHEALTH CORPORATION 16 May 2003 11 December 2003
Healthcare eligibility and benefits data system NXGN MANAGEMENT, LLC 28 July 2006 31 January 2008
Systems and methods for determining indications of fraud in healthcare claims TC3 HEALTH, INC. 26 June 2006 11 January 2007
See full citation <>

More like this

Title Current Assignee Application Date Publication Date
Healthcare debit card linked to healthcare-related and non-healthcare-related financial accounts METAVANTE CORPORATION 27 February 2007 29 April 2009
System and Method for Storing Health Information and Adjudicating Insurance Claims WEISS, SHELDON G. 28 August 2015 24 December 2015
System and method for insuring against unrecoverable litigation costs YOUNG, TIMOTHY, J. 04 September 2015 21 July 2016
Systems and methods for facilitating transactions between healthcare consumers and healthcare providers ELUMINATE HEALTH, LLC 06 February 2015 12 May 2016
Method and system to identify dominant patterns of healthcare utilization and cost-benefit analysis of interventions KONINKLIJKE PHILIPS N.V. 28 December 2016 06 July 2017
Method for supporting medical expenses, and medical expense providing system JUNG, SE YOUNG 04 January 2017 13 July 2017
Insurance premium claim settlement method and system for automobile logistics SHI, LI 01 August 2016 08 February 2018
System and method for decentralized autonomous healthcare economy platform POKITDOK, INC. 03 August 2016 09 February 2017
Integrated healthcare performance assessment tool focused on an episode of care KONINKLIJKE PHILIPS N.V. 25 October 2016 04 May 2017
Hospital matching of de-identified healthcare databases without obvious quasi-identifiers KONINKLIJKE PHILIPS N.V. 17 October 2016 04 May 2017
System and method of identifying baker's fraud in transactions MASTERCARD INTERNATIONAL INCORPORATED 14 December 2016 22 June 2017
Fast and accurate search generating a ranked list of healthcare providers AMINO, INC. 31 March 2016 09 March 2017
System and method for remote provision of healthcare TSE, EDMUND YEE-LAI,IYNGKARAN, GURUPARAN 09 August 2017 22 February 2018
Automated exchange of healthcare information for fulfillment of medication doses BAXTER CORPORATION 26 October 2015 28 April 2016
Dynamic analysis of health and medical data ABRAMOWITZ, MARC, LAUREN 29 October 2015 06 May 2016
System and method for identifying suspicious healthcare behavior GEORGIA TECH RESEARCH CORPORATION 06 March 2017 08 September 2017
System and method for dynamic healthcare insurance claims decision support POKITDOK, INC. 06 June 2017 14 December 2017
Systems and methods for determining healthcare quality measures by evaluating subject healthcare data in real-time KONINKLIJKE PHILIPS N.V. 30 May 2017 14 December 2017
Computerized system and method of open account processing CROWE HORWATH, LLP 07 March 2017 14 September 2017
Healthcare resource availability and allocation systems and methods KURE TECHNOLOGY SERVICES, LLC. 05 August 2016 16 February 2017
See all similar patents <>

More Patents & Intellectual Property

PatSnap Solutions

PatSnap solutions are used by R&D teams, legal and IP professionals, those in business intelligence and strategic planning roles and by research staff at academic institutions globally.

PatSnap Solutions
Search & Analyze
The widest range of IP search tools makes getting the right answers and asking the right questions easier than ever. One click analysis extracts meaningful information on competitors and technology trends from IP data.
Business Intelligence
Gain powerful insights into future technology changes, market shifts and competitor strategies.
Workflow
Manage IP-related processes across multiple teams and departments with integrated collaboration and workflow tools.
Contact Sales
Clsoe
US10002391 Method detecting preventing 1 US10002391 Method detecting preventing 2