Patient credit balance account analysis, overpayment reporting, and recovery tools

Abstract

The present invention provides a system for managing, analyzing and reporting accounts of overpaid claims for patient balance accounts, although various components and features of the system are inventions into themselves. Certain aspects of the inventor allow managers of both service providers (such as health care facilities) and payers (such as insurance companies and Medicare) to assign work and produce reports. Other aspects of the invention allow provider users and payer users to analyze and resolve the claims in an automated environment. These aspects provide the users with information in a readily accessible and easy to navigate format. The users are also provided with tools for analyzing the claims in an automated manner.

1 . A claim retraction system, implemented by a processing system including at least one processing device for interfacing between healthcare service providers and payers, the claim retraction system comprises:
 an automatic claim identification and reporting module configured to report claims to the payers;   a payer/provider information exchange module configured to report overpaid claims by the provider to the payer in a format required by the payer;   a payer workload management module configured to accept an input by a payer manager to assign overpaid claims to payer users;   a payer management reporting module configured to prepare forms of overpaid claims; and   a claim search/remittance retrieval module configured to search payer paid claims in response to an input by provider users.   
     
     
         2 . The system of  claim 1 , wherein the automatic claim identification and reporting module comprises:
 on a condition that payer and provider claim data is available, a link creation component configured to create a link between the payer and the provider claim data;   an adjuster component configured to process a refund and perform a search for a claim matching an overpaid claim within the payer claim data, wherein the matching claim is detected based on a subscriber identifier (ID), date of service (DOS), payment amount, and payment date; and   on a condition that a matching claim is found, the system is configured to report the overpaid claim.   
     
     
         3 . The system of  claim 2 , further comprising:
 on a condition that the matching claim is not found, the adjuster component is further configured to perform a search for potential overpaid claims, within the payer claim data among a payer's paid claims, based on at least one of: subscriber ID, DOS, or payment amount;   the adjuster component further configured to select one of the potential matching claims; and   the system is further configured to report the overpaid claim.   
     
     
         4 . The system of  claim 1 , wherein the payer/provider information exchange module comprises:
 a reporting component configured to generate a report including a provider identified overpaid claim to a payer.   
     
     
         5 . The system of  claim 1 , wherein the payer/provider information exchange module further comprises:
 a review component configured to allow payer review of a claim and determine whether additional information required for retraction is present.   
     
     
         6 . The system of  claim 5 , wherein on a condition that data elements are missing, the payer/provider information exchange module further comprises:
 an information requester component configured to request additional information from a provider adjuster component, receive the additional information from the provider adjuster component, and send the additional information to the payer.   
     
     
         7 . The system of  claim 1 , further comprising:
 the payer review component further configured to review the overpaid account information and assign a status indicator to an overpaid account, wherein the status indicator includes an indication that conveys at least one of: in progress, retracted, need information from provider, or canceled by the payer.   
     
     
         8 . The system of  claim 7 , wherein on a condition that the account status indicates that information is required from provider, the payer review component is further configured to send a message to the provider adjuster component including an information request. 
     
     
         9 . The system of  claim 7 , further comprising:
 the provider adjuster component further configured to identify an account having a status indicating that provider information is required;   the provider adjuster component further configured to:
 select a claim requiring provider information based on the identified account, along with detailed information and the message including the information request corresponding to the identified account; 
 gather the requested information; 
 send a message to the health care payer with the gathered information; and 
 change the status indicator of the selected account. 
   
     
     
         10 . The system of  claim 9 , further comprising:
 the payer/provider information exchange module further configured to provide a payer with a list of claims for which the gathered information was sent;   on a condition that the information is sufficient to retract the account, the payer/provider information exchange module is further configured to retract the account and change the account status; and   on a condition that the information is not sufficient to retract the account, the payer/provider information exchange module is further configured to change the status indicating that processing is in progress or that the account is canceled.   
     
     
         11 . The system of  claim 10 , wherein the payer or the provider changes the account status and provide a message explaining the status change, and wherein on a condition that the payer changed the status, the message is provided to a corresponding provider, or on a condition that the provider changed the status, the message is provided to the corresponding payer. 
     
     
         12 . The system of  claim 1 , wherein the payer management reporting module is further configured to generate reports and forms including at least one of: refund reports, detail invoice reports, retraction request forms or custom reports. 
     
     
         13 . The system of  claim 1 , wherein the payer management reporting module comprises:
 a payer management component configured to select a report or form to generate; and   the payer management component further configured to select a provider, wherein the provider is selected by performing a search and the search options include at least one of: payer, line of business (LOB), begin date, end date, check number, type of recovery, reporting status, or invoice number.   
     
     
         14 . A method for claim retraction, implemented by a processing system including at least one processing device for interfacing between healthcare service providers and payers, the method comprising:
 reporting of claims to the payers by the processing system;   reporting overpaid claims by the provider to the payer in a format required by the payer by the processing system;   assigning by the processing system overpaid claims to payer users in reponse to an input by a payer manager;   preparing forms of overpaid claims by the processing system; and   searching by the processing system payer paid claims in response to an input by provider users.