Novel Method and Apparatus For Repricing a Reimbursement Claim Against a Contract6

Abstract

A method for repricing a reimbursement claim under at least one contract is provided herein. The method may include a combination of steps such as: converting each contract into a series of contractual terms; converting a claim into a series of claim lines, containing claim codes, unit numbers and corresponding charges for the claim codes; comparing claim codes and contractual terms and identifying matches therebetween; determining any priority conditions associated to the matching contractual terms, and eliminate any matching contractual terms that are excluded by the priority conditions; calculating the reimbursement amount for the claim by determining the reimbursement charges for the non-excluded matching contractual terms; and determining and making any adjustments depending upon any discount terms for the entire reimbursement amount.

We claim: 
     
         1 . A computer implemented method for repricing a claim for reimbursement under a contract comprising:
 converting the claim by the repricing engine into a series of claim lines, each claim line containing a claim code and each claim line having an initial amount associated therewith;   comparing by the repricing engine each claim code, of the series of claim lines, against a rate sheet of the contract, the rate sheet including multiple predefined sections and multiple priority conditions for determining a sequence of comparing each claim code against the multiple predefined sections of the rate sheet; and   determining by the repricing engine a reprice amount under the contract for the claim based on the comparison in accordance with the determined sequence.   
     
     
         2 . The computer implemented method of  claim 1 , further comprising:
 comparing by the repricing engine each claim code, of the series of claim lines, against a first predetermined section of the contract containing exclusion codes;   determining if any of the claim codes match any of the exclusion codes;   excluding matching claim codes from determining a reprice amount under the contract.   
     
     
         3 . The computer implemented method of  claim 2 , further comprising:
 comparing by the repricing engine each non-excluded claim code, of the series of claim lines, against a second predetermined section of the contract containing case rate codes;   for each non-excluded claim code substantially matching a case rate code, determining by the repricing engine which contractual terms of the matching case rate code apply; and   applying by the repricing engine the applicable case rate contractual terms to the claim for reimbursement to determine the reprice amount under the contract for the claim.   
     
     
         4 . The computer implemented method of  claim 3 , further comprising:
 comparing by the repricing engine each non-excluded, non-matching claim code, of the series of claim lines, against a third predetermined section of the contract containing per diem codes when it is determined that no non-excluded claim code substantially matches a case rate code;   for each non-excluded claim code substantially matching a per diem code, determining by the repricing engine which contractual terms of the matching per diem code apply; and   applying by the repricing engine the applicable per diem contractual terms to each claim line of each matching non-excluded claim code to determine a reprice amount for each claim line.   
     
     
         5 . The computer implemented method of  claim 4 , further comprising:
 comparing by the repricing engine remaining claim codes, of the series of claim lines, against a fourth predetermined section of the contract containing service codes when it is determined that no non-excluded claim code substantially matches a case rate code or a per diem code;   for each remaining claim code substantially matching a service code, determining by the repricing engine which contractual terms of the matching service code apply; and   applying by the repricing engine the applicable service contractual terms to each claim line of each matching remaining claim code to determine a reprice amount for each claim line.   
     
     
         6 . The computer implemented method of  claim 5 , further comprising:
 adding by the repricing engine the repriced amounts for each claim line and the initial amounts for each claim line associated with an excluded claim code to determine a preliminary repriced claim total;   comparing by the repricing engine the preliminary repriced claim total with a stop loss total of the rate sheet; and   assigning by the repricing engine the preliminary repriced claim total as a final repriced claim total when the preliminary repriced claim total does not exceed the stop loss total.   
     
     
         7 . The computer implemented method of  claim 6 , further comprising:
 assigning to the claim by the repricing engine a revised repriced claim total when the preliminary repriced claim total exceeds the stop loss total, wherein the revised repriced claim total is a predetermined percentage of the preliminary repriced claim total.   
     
     
         8 . The computer implemented method of  claim 1  further including:
 selecting by the repricing engine a governing contract from multiple contracts, wherein each of the multiple contracts includes a unique contract identifier code by comparing by a claim identifier code of the claim for reimbursement against the unique contract identifier code for each of the multiple contracts, and when the claim identifier code is substantially equal to a contract identifier code, identifying the one of the multiple contracts associated with the substantially equal contract identifier code as the governing contract, wherein the repricing of the claim for reimbursement is repriced only against the governing contract. 
 
     
     
         9 . The computer implemented method of  claim 8  wherein the step of repricing the claim further includes:
 when at least two of the multiple contracts are identified as governing contracts, repricing by the repricing engine the claim for reimbursement against each of the identified multiple governing contract and creating a list of multiple governing repriced amounts. 
 
     
     
         10 . The computer implemented method of  claim 9  further comprising:
 determining by the repricing engine a lowest governing repriced amount from the list of governing repriced amounts, wherein the lowest governing repriced amount is the repriced amount of the claim. 
 
     
     
         11 . The computer implemented method of  claim 10  further comprising: storing by the computer the repriced amount of the claim and storing the claim as a repriced claim. 
     
     
         12 . The computer implemented method of  claim 11  wherein prior to determining the reimbursement amount for a claim the method including: comparing the claim identifier code, of said claim, against the claim identifier codes, of all stored repriced claims;
 when the claim identifier code, of said claim is substantially equal to the claim identifier codes, of a stored repriced claim, combining the claim lines of said claim with the claim line of said repriced claim creating a bundled claim; 
 determining by the repricing engine a repriced amount of the bundled claim, instead of determining a repriced amount of said claim; and 
 rewriting the repriced amount of the stored repriced claim with the repriced amount of the bundled claim and rewriting the stored claim with the bundled claim. 
 
     
     
         13 . A system for repricing a claim for reimbursement under a contract, the system comprising:
 a contract platform for creating a rate sheet in accordance with terms of the contract, the rate sheet including at least the following predefined sections against which a claim for reimbursement is compared for repricing an exclusion section, a case rate section, a per diem section, a services section, and a stop loss section and further including, wherein each of the predetermined sections includes one or more contract codes which are associated with one or more qualification terms and repricing calculation rates of the contract; and   a repricing engine for comparing a claim code of each claim line of the claim for reimbursement to the rate sheet to reprice the claim.   
     
     
         14 . The system of  claim 13 , wherein the repricing engine comprises:
 programming code for applying the terms of the contract to the claim in accordance with priority conditions defined in the rate sheet for determining a sequence of comparing each claim code against the multiple predefined sections therein.   
     
     
         15 . The system of  claim 14 , wherein the repricing engine comprises:
 programming code for comparing each claim code, of the series of claim lines, against at least one exclusion code in the exclusion section, determining if any of the claim codes match the at least one exclusion code; and excluding matching claim codes from determining a reprice amount under the contract.   
     
     
         16 . The system of  claim 15 , wherein the repricing engine comprises:
 programming code for comparing each non-excluded claim code, of the series of claim lines, against at least one case rate code in the case rate section and for each non-excluded claim code substantially matching at least one case rate code, determining which contractual terms of the matching case rate code apply and applying the applicable case rate contractual terms to the claim for reimbursement to determine the reprice amount under the contract for the claim.   
     
     
         17 . The system of  claim 16 , wherein the repricing engine comprises:
 programming code for comparing each non-excluded, non-matching claim code, of the series of claim lines, against at least one per diem code in the per diem section when it is determined that no non-excluded claim code substantially matches the at least one case rate code and for each non-excluded claim code substantially matching the at least one per diem code, determining by which contractual terms of the matching per diem code apply and applying by the applicable per diem contractual terms to each claim line of each matching non-excluded claim code to determine a reprice amount for each claim line.   
     
     
         18 . The system of  claim 17 , wherein the repricing engine comprises:
 programming code for comparing remaining claim codes, of the series of claim lines, against at least one services code of the services section when it is determined that no non-excluded claim code substantially matches the at least one case rate code or the at least one per diem code and for each remaining claim code substantially matching the at least one service code, determining which contractual terms of the matching service code apply and applying the applicable service contractual terms to each claim line of each matching remaining claim code to determine a reprice amount for each claim line.   
     
     
         19 . The system of  claim 18 , wherein the repricing engine comprises:
 programming code for adding the reprice amounts for each claim line and an initial amount for each claim line associated with an excluded claim code to determine a preliminary repriced claim total and comparing the preliminary repriced claim total with a stop loss total of the rate sheet and assigning the preliminary repriced claim total as a final repriced claim total when the preliminary repriced claim total does not exceed the stop loss total.   
     
     
         20 . The system of  claim 19 , wherein the repricing engine comprises:
 programming code for assigning to the claim a revised repriced claim total when the preliminary repriced claim total exceeds the stop loss total, wherein the revised repriced claim total is a predetermined percentage of the preliminary repriced claim total.