HEALTH CARE PAYMENT ADJUDICATION AND REVIEW SYSTEM

摘要

A computerized expert system reviews and adjudicates medical health carepayment requests made by physicians to payers, such as insurers, forproceduresperformed and services and materials rendered to patients in the course oftreatment. The system adjudicates a payment request to minimize fraud andmistakes and to determine whether to honor the request and if the request ishonored, the dollar amount of the payment. The expert system reviews thepayment request based on user-specified review criteria. Such criteriareflectscontractual arrangements between payers, providers and patients, current,locallyacceptable medical practices and patient and provider payment requestpatterns.To perform the review, the expert system obtains relevant prior paymentrequests as necessary according to the user's pre-determined review criteria;definesa master list of payable payment requests given current medical procedures,the pre-determined parameters of the review and specific contractual arrangementsbetweenthe payer, patient and health care provider; analyses the current paymentrequestaccording to the relevant historical payment requests and the master payablelist byapplying user-defined interpretive rules to this information; and develops andreports payment decisions based on that analysis.