System and method for data quality assurance cycle

Abstract

A system and method for automated quality assurance including a quality assurance application server for managing quality assurance. The quality assurance application server includes an application configuration module which has a data configuration module configured to define configurable reference fields to be captured and reviewed during the processing of the records. The application configuration module also has a rules configuration module to receive, create or modify a set of rules where the configurable reference fields are selectable when the rules are defined. The system also includes a portal module for processing the received records and applying the set of rules to the record. The portal module includes a quality assurance records review module configured to evaluate and validate the received records and to generate an output utilized to validate the record to ensure compliance with a data recipient, for example payer billing, standards.

1 . A system, comprising:
 a non-transitory computer readable storage device configured to store executable programmed modules;   at least one processor communicatively coupled with the non-transitory computer readable medium configured to execute programmed modules stored therein; and   one or more executable software modules that, when executed by the at least one processor,
 receives a first patient data record and a second patient data record, 
 compares the first patient data record to the second patient data record, 
 identifies at least one inconsistency between a first field included in the first patient data record and a first field included in the second patient data record, 
 flags the first field included in the first patient data record and the first field included in the second patient data record, and 
 assigns the first patient data record to a reviewer for quality assurance review prior to generating a first claim based on at least one of the first patient data record and the second patient data record. 
   
     
     
         2 . The system of  claim 1 , wherein the one or more executable software modules identifies the at least one inconsistency in accordance with a content of the first field included in the first patient data record and a content of the first field included in the second patient data record. 
     
     
         3 . The system of  claim 1 , wherein the one or more executable software modules identifies the at least one inconsistency in accordance with a format of the first field included in the first patient data record and a format of the first field included in the second patient data record. 
     
     
         4 . The system of  claim 1 , wherein the one or more executable software modules further generates the first claim based on at least one of the first patient data record and the second patient data record, and determines, based on at least one of the first patient data record and the second patient data record, that the first claim is associated with a first payer. 
     
     
         5 . The system of  claim 4 , wherein the one or more executable software modules further validate the first claim based at least in part on a first set of rules determined by the first payer. 
     
     
         6 . The system of  claim 5 , wherein validating the first claim includes editing the first claim such that the first claim is compliant with the first set of rules determined by the first payer. 
     
     
         7 . The system of  claim 5 , wherein the one or more executable software modules further validates a second claim generated based on at least one of the first patient data record and the second patient data record, wherein the second claim is associated with a second payer, and wherein validating the second claim includes editing the second claim such that the second claim is compliant with a second set of rules determined by the second payer. 
     
     
         8 . A method comprising, by at least one hardware processor:
 receiving a first patient data record and a second patient data record;   comparing the first patient data record to the second patient data record;   identifying at least one inconsistency between a first field included in the first patient data record and a first field included in the second patient data record,   flagging the first field included in the first patient data record and the first field included in the second patient data record; and   assigning the first patient data record to a reviewer for quality assurance review prior to generating a first claim based on at least one of the first patient data record and the second patient data record.   
     
     
         9 . The method of  claim 8 , wherein the at least one inconsistency is identified in accordance with a content of the first field included in the first patient data record and a content of the first field included in the second patient data record. 
     
     
         10 . The method of  claim 8 , wherein the at least one inconsistency is identified in accordance with a format of the first field included in the first patient data record and a format of the first field included in the second patient data record. 
     
     
         11 . The method of  claim 8 , further comprising:
 generating the first claim based on at least one of the first patient data record and the second patient data record; and   determining, based on at least one of the first patient data record and the second patient data record, that the first claim is associated with a first payer.   
     
     
         12 . The method of  claim 11 , further comprising validating the first claim based at least in part on a first set of rules determined by the first payer. 
     
     
         13 . The method of  claim 12 , wherein validating the first claim includes editing the first claim such that the first claim is compliant with the first set of rules determined by the first payer. 
     
     
         14 . The method of  claim 12 , further comprising validating a second claim generated based on at least one of the first patient data record and the second patient data record, wherein the second claim is associated with a second payer, and wherein validating the second claim includes editing the second claim such that the second claim is compliant with a second set of rules determined by the second payer. 
     
     
         15 . A non-transitory computer readable medium having stored thereon one or more sequences of instructions for causing one or more processors to perform steps comprising:
 receiving a first patient data record and a second patient data record;   comparing the first patient data record to the second patient data record;   identifying at least one inconsistency between a first field included in the first patient data record and a first field included in the second patient data record,   flagging the first field included in the first patient data record and the first field included in the second patient data record; and   assigning the first patient data record to a reviewer for quality assurance review prior to generating a first claim based on at least one of the first patient data record and the second patient data record.   
     
     
         16 . The medium of  claim 15 , wherein the at least one inconsistency is identified in accordance with a content of the first field included in the first patient data record and a content of the first field included in the second patient data record. 
     
     
         17 . The medium of  claim 15 , wherein the at least one inconsistency is identified in accordance with a format of the first field included in the first patient data record and a format of the first field included in the second patient data record. 
     
     
         18 . The medium of  claim 15 , wherein the steps further comprise:
 generating the first claim based on at least one of the first patient data record and the second patient data record;   determining, based on at least one of the first patient data record and the second patient data record, that the first claim is associated with a first payer; and   validating the first claim based at least in part on a first set of rules determined by the first payer.   
     
     
         19 . The medium of  claim 18 , wherein validating the first claim includes editing the first claim such that the first claim is compliant with the first set of rules determined by the first payer. 
     
     
         20 . The medium of  claim 18 , wherein the steps further comprise validating a second claim generated based on at least one of the first patient data record and the second patient data record, wherein the second claim is associated with a second payer, and wherein validating the second claim includes editing the second claim such that the second claim is compliant with a second set of rules determined by the second payer.