Systems and Methods for Facilitating Insurance Coverage

Abstract

Electronically generated information for facilitating the efficient and effective authorization of a medical procedure, treatment or medicine is provided. The information is specific to a patient's insurance company, medical need and diagnosis. An electronic database has been configured for analysis by a user such that inputs to the database result in outputs considered necessary in a preparation and submission for authorization of the medical procedure, treatment or medicine.

1 . A computer-implemented method for facilitating reimbursement of a medical procedure claim, for payment from a third-party payor for a medical procedure for a patient, performed by a computing device having a software-based search engine and an electronic database, said method comprising:
 receiving, with the computing device operated by a user, patient data wherein the patient data comprises one or more of the third-party payor, a policy or plan, and the medical procedure;   identifying inputs from the patient data, wherein the inputs are selected from, demographic information, indications, the third-party payor, the policy, and the medical procedure;   configuring the electronic database to provide outputs in a form of specific patient criteria and indications, needed to show that the medical procedure is medically necessary, for the patient's approval for the medical procedure claim based on:
 a history of previous medical procedure claim submissions based on treating other patients with similar inputs to the patient and 
 whether the previous medical procedure claim submissions were authorized by third-party payor; 
   searching, by the computing device and via the software-based search engine, the electronic database with the inputs, for the outputs that include the specific patient criteria and indications to facilitate a finding of an authorization for the medical procedure claim wherein the outputs are provided as a document setting forth the extracted patient data that meets the specific patient criteria needed for authorization;   determining, by the computer device, which one or more of the outputs do not meet the specific patient criteria;   receiving the outputs specific to the third-party payor of the patient which describe how the patient meets a third-party payor's approval criteria and that facilitate the authorization for the medical procedure claim; and   automatically generating a report that discloses the outputs specific to the third-party payor of the patient which describe how the patient meets a third-party payor's approval criteria and discloses the outputs that do not meet the specific patient criteria.   
     
     
         2 . The method of  claim 1 , wherein the medical procedure involves one or more of medical testing, medical services, medical exams, diagnostic testing, medications, surgical procedures, implants, transplants, psychological exams, psychological studies, pharmaceuticals, rehabilitation/therapies, and prosthetics. 
     
     
         3 . The method of  claim 2 , wherein the inputs further include one or more of: a type of examination, an exam description, diagnostic results, exam results, patient symptoms, prior surgical and non-surgical treatment, a type of implant, a type of therapy or biologics, implant site health, patient health, patient demographics, and patient rehabilitation involvement. 
     
     
         4 . The method of  claim 1 , further comprising identifying one or more of pertinent clinical support data, medical literature, and expert opinions to address the one or more of the outputs that do not meet the specific patient criteria and still providing medical justification for the medical procedure. 
     
     
         5 . The method of  claim 4 , further comprising receiving the one or more of the pertinent clinical support data, the medical literature, and the expert opinions that address the outputs that do not meet the specific patient criteria. 
     
     
         6 . The method of  claim 5 , further comprising providing, by the computer device, one or more of additional pertinent clinical support data, additional medical literature, and additional expert opinions that provide medical justification for the medical procedure when the insurance company has previously determined the medical procedure is not medically necessary. 
     
     
         7 . The method of  claim 6 , wherein automatically generating the report includes generating the report in the form of a document describing medical necessity based on the outputs and including a request for the authorization of the medical procedure claim. 
     
     
         8 . The method of  claim 7 , wherein automatically generating the report includes generating the report disclosing the one or more of the pertinent clinical support data, the medical literature, and the expert opinions addressing the outputs that do not meet the specific patient criteria. 
     
     
         9 . The method of  claim 8 , wherein automatically generating the report includes generating the report disclosing the one or more of the additional pertinent clinical support data, the additional medical literature, and the additional expert opinions that provide medical justification for the medical procedure. 
     
     
         10 . The method of  claim 9 , wherein the report is in the form of a document describing medical necessity and further comprising submitting the report to the third-party payor. 
     
     
         11 . The method of  claim 1 , wherein the patient data is compiled from one or more of relevant insurance information, physician referrals, patient history, physician reports, medical imaging, electronic records, and clinical information. 
     
     
         12 . The method of  claim 1 , wherein the electronic database further includes payor policy coverage information, medical literature and clinical support data. 
     
     
         13 . The method of  claim 1 , wherein configuring the electronic database includes screening all specific indications and contraindications for each medical procedure for the specific patient criteria needed to be considered medically necessary. 
     
     
         14 . The method of  claim 1 , wherein facilitating the authorization for the medical procedure claim includes supporting an appeals process after a denial is received from the third-party payor. 
     
     
         15 . The method of  claim 1 , wherein the outputs specify a specific procedure for submitting one or more of the medical procedure claim, an appeal, and the authorization for the medical procedure claim. 
     
     
         16 . A system for facilitating reimbursement of a medical procedure claim for payment from a third-party payor for a medical procedure for a patient, said system comprising:
 a computer having a software-based search engine and a memory storing: a patient's data, wherein the patient data comprises one or more of the third-party payor, a policy or plan, and the medical procedure;   said computer configured to:
 identify inputs from the patient data, wherein the inputs are selected from, demographic information, indications, third-party payor, the policy, and the medical procedure; 
 configure the electronic database to provide outputs, in a form of specific patient criteria and indications, needed to show that the medical procedure is medically necessary for the patient's approval for the medical procedure claim, based on a history of previous medical procedure claim submissions, treatment of other patients with similar inputs to the patient and whether the previous medical procedure claim submissions were authorized by the third party payor; 
 search, via the software-based search engine, the electronic database with the inputs, for the outputs that include the specific patient criteria and indications to facilitate a finding of an authorization for the medical procedure claim wherein the outputs are provided as a document setting forth the extracted patient data that meets the specific patient criteria needed for authorization; 
 determine, which one or more of the outputs do not meet the specific patient criteria; 
 receive the outputs specific to the third-party payor of the patient which describe how the patient meets a third-party payor's approval criteria and that facilitate the authorization for the medical procedure claim; and 
 automatically generate a report that discloses the outputs specific to the third-party payor of the patient which describe how the patient meets the third-party payor's approval criteria and discloses the outputs that do not meet the specific patient criteria. 
   
     
     
         17 . The system of  claim 16 , wherein the inputs further include one or more of: a type of examination, an exam description, diagnostic results, exam results, patient symptoms, prior surgical and non-surgical treatment, a type of implant, a type of therapy or biologics, an implant site health, patient health, patient demographics, and patient rehabilitation involvement. 
     
     
         18 . The system of  claim 16 , wherein the report includes one or more of: pertinent clinical support data, medical literature, and expert opinions to address the one or more of the outputs that do not meet the specific patient criteria, and still provides medical justification for the medical procedure. 
     
     
         19 . The system of  claim 18 , wherein the report includes the one or more of: pertinent clinical support data, medical literature, and expert opinions that address the outputs that do not meet the specific patient criteria. 
     
     
         20 . The system of  claim 19 , wherein the report includes one or more of: additional pertinent clinical support data, additional medical literature, and additional expert opinions that provide medical justification for the medical procedure when the insurance company has previously determined the medical procedure is not medically necessary