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The account is also checked to see if the account only has one payment, step The ASM preferably determines whether the account has any adjustments during step If the account includes adjustments, the ASM checks whether the sum of the adjustments is greater than or equal to the total account charges, step If so, the account is marked i. The ASM preferably determines whether there are any open debit accounts for the same person listed on the account being examined, step If so, the ASM checks whether the debit balance is equal to the absolute value of the credit balance, step If during step , the ASM determines that the debit balance is greater than the absolute value of the credit balance in the account being examined, the account is marked i.

The indicators above indicators are summarized below in Table 5. B Patient payment is greater than or equal to the account balance C Duplicate adjustments D Adjustment equals account balance E Adjustment equals the inverse of the total charges F Duplicate payments G Payment equals account balance H Only a single payment in the account I Account has no payments J Sum of adjustments is greater than or equal to total charges K Separate account for same patient has a debit balance equal to the absolute value of the credit balance in the examined account L Separate account for same patient has a debit balance greater than the absolute value of the credit balance in the examined account M Total charges in account equal zero.

Table 6 lists level 1 criteria. Any account not meeting the level 1 criteria and having the tenth indicator is checked by the ASM to determine whether any level 2 criteria is met and assigns a score of 4 to those accounts meeting a level 2 criteria, steps , The level 2 criteria are set forth in Table 7 below. Any accounts that are not considered level 1 or 2 are designated as level 3 and are scored based on the level 3 criteria, step For each of the level 3 criteria that the account meets, the corresponding point value as shown in Table 8 below is summed.

To illustrate, an account meeting indicators C and H is assigned a score of 2. The standard scoring module does not assign account designations and resolutions. The ASM provides greater consistency between the designations assigned to accounts and the provision of possible resolutions by combining both functions.

When determining possible resolutions, each account is categorized and prioritized by the ASM based on the factors or financial transactions that most likely caused the account to be in a credit balance status. Such factors include, for example, potential excess patient payments and excess allowance posting.

The following checks for possible account resolutions and designations are preferably performed in the order described below. Once an account has been assigned a possible resolution and a designation, the ASM provides the data to a user or stores the data with the account as desired. The amount of language included in the possible resolution can be varied depending on the amount of information desired by the account adjuster or an institution using the ASM. If so, the ASM further examines the account to see if indicator G is also set, step If so, the ASM further examines the account to see if indicator H is also set, step If indicator K is set, but not indicator H, then the ASM further examines the account to see if indicator B is set, step If so, the ASM further examines the account to see if indicator L is also set, step If indicator B is set, but not indicator L, then the ASM further examines the account to see if indicator M is set, step The ASM can preferably use two types of designations, primary and secondary, that may be assigned to each account.

All accounts will receive a primary designation. The Medicare designation is used to flag accounts that have at least one outstanding Medicare account, while the secondary designation is used to give a more accurate description of the true cause of the credit balance.

During step , the ASM checks whether a designation has already been recorded in a Primary designation data location associated with the account.

If no primary designation has been assigned, then the selected designation is placed in the primary designation data location during step If the primary designation has been filled already, then, during step , the selected designation is placed in a secondary designation data storage location associated with the account.

Since the preferred ASM checks for Medicare payments prior to assigning designations, the primary designation will always be populated when the account includes Medicare payments. While the preferred system allocates two designation data locations for each account, those of ordinary skill in the art will appreciate from this disclosure that any number of designation data locations can be provided without departing from the scope of the present invention.

While specific indicators, possible resolutions, and designations are preferred and described above, those of ordinary skill in the art will appreciate from this disclosure that various combinations or alternative criteria can be used by the ASM without departing from the scope of the present invention. Furthermore, accounts need not be limited to having one possible resolution and designation. Depending on the criteria being used, multiple sequential checks can be allowed after identifying an initial possible resolution and designation without departing from the present invention.

To aid an adjustor to handle an account, each account is assigned an account designation as illustrated in the flow chart of FIG. The account designation is preferably displayed on the payment screen on the presentation screens. Initially, each account is analyzed to determine whether it has any outstanding Medicare payments, step The account is checked to see if any Medicare payments were received on the account. These payments are identified by the service code associated with the transaction and are marked as Medicare transactions.

If any of an account's transactions are Medicare transactions, the account table is marked to indicate that this account has Medicare payments, step Since each account is analyzed during the scoring procedure, the marking of Medicare payments is preferably performed during scoring. If the account does not meet any of the prior designation, it is checked to see if it has scoring indicators 4 , 2 , 6 or 9 , steps , , If the account has any of those indicators, it likely has an allowance error, step The account assignment tool allows a manager to effectively assign accounts to users as shown in the flow chart of FIG.

The assignment tool stores for each user the accounts assigned to the user. When the user resolves an account, that account is removed from the user assignment. To assign accounts, the manager selects a user from a list of users for such an assignment, step A screen is displayed indicating the number of accounts assigned to the user.

If the manager desires to change the users' current assignment, the manager preferably has the ability to edit by removing and adding assignments to the users list of current assignments. Step To aid the manager in assigning new accounts, the manager is preferably provided with three quick fill options. These quick fill options are preferably selectable buttons on the GUI.

These accounts have at least one Medicare payment. These errors, indicators 4 , 2 , 6 and 9 , typically result in an under reporting of revenues for the health care facility.

These accounts, having indicator 7 , likely have a patient over payment. The account assignment tool also allows the manager to assign accounts by querying the patient account application server database. A preferred query screen has three columns. The first column is the search field. The second column is for the operator. The third column is for the value, such as text or numeric. After all the accounts for a query are retrieved, the accounts are preferably checked to verify that they are not checked out or currently assigned to another user.

The results of the search are displayed to the manager. After the assignment is verified, the manager can assign these accounts to the user. The account assignment tools allow a manager to control the user workload using a workload estimation report. To derive the workload estimation report, an estimated average time period to resolve each account is determined. A preferred time estimator user the account designation and the score to estimate the average time to resolve an account.

A preferred table for estimating the time in minutes for a single account having a particular designation and score is per Table 9.

Using the average amount of time to resolve an account, a workload estimate for unresolved accounts can be determined. The workload estimation report shows the estimated time expected to resolve the unresolved accounts by their designation and score. As shown for the preferred report, the designation of account and the score is shown in the left column. The number of accounts in each designation having a particular score are listed in a second column from the left.

The average time, in minutes, to resolve each of these types of accounts is in the third column. Along the bottom of the report is preferably total for the number of accounts, the total time required in minutes and the total time in hours. Using this report, a manager has more detailed information to better allocate the manager's user resources. To illustrate, if a Medicare report is due at the end of the month, the manager can determine whether overtime or hiring additional users is required to resolve these accounts.

The system of the present invention preferably includes a report generation module. This report module allows reports to be generated, as needed, to assist hospitals in the management of credit balance accounts. These reports are generated using data collected during the processing of patient accounts. By monitoring system usage and collecting adjuster data, the system can generate reports on staff productivity, system usage, refunds and allowances processed by an adjuster, transaction reports, and fraud exception reports.

There are preferably at least four report categories: audit reports, management reports, profit reports and administrative reports. The audit reports are preferably available for all adjusters to generate specific reports.

The audit report allows an adjuster to view transactions related to a specific health care provider. When the adjuster enters the audit report section, they are preferably asked to provide the name of the health care provider of interest and the date range for transactions for that provider.

One method of entering the appropriate selections into the system involves using a drop down menu system. A drop down menu system preferably includes a drop down menu of providers associated with an adjuster's account an adjuster's account may include many separate patient accounts.

If a specific selection is not made by the adjuster, the provider drop down menu defaults to all of the providers associated with the adjusters account. Once the provider and date range have been entered, the search can be submitted to the system. Once the search has been submitted, the reports will be generated based on retrieved information that falls within the date range of interest. If the date range is left blank, the report will preferably include all transactions performed by the adjuster involving the provider of interest.

Once the transactions involving a desired provider during a specific date range are identified, the adjuster can generate reports detailing one of many variables of interest. Once the user selects the desired variable to use to prepare the report, the appropriate data is sent to the Report building Module. The Report Module retrieves the appropriate data and template, and then generates the desired report.

It is preferable that the amount of detail included in a report is customized depending on the particular person requesting the report. For example, if the requester is an adjuster, the data returned will be based on the patient accounts and audit transactions for which the adjuster is responsible. If the requester is a manager, then it is preferred that all transactions involving the selected provider and occurring within the date range is retrieved and included in the report.

While the above mentioned reports are detailed below, the present invention is not limited to such reports. Those of ordinary skill in the art will appreciate that the system can be used to generate any desired reports based on data that is collected by the system. As such, the system can be customized to generate reports that are a combination of the reports described herein.

The possible errors report retrieves account level details of accounts that may contain audit errors and formats them in an easy to read spreadsheet which makes reviewing refund information easy. The transaction report details each transaction code, amount and audit explanation for each account that falls within the desired date range.

The Summary of refunds report summarizes refunds by audit, payer, number of refunds and total dollars refunded for a particular batch or range of batches. The Summary of transactions report summarizes transactions by type, audit and amount for a particular batch or range of batches.

The Insurance Priority Changes report will retrieve information on any insurances that had priorities changed based on the search criteria.

The report will display the patient name, account number, insurance name, original priority code, new priority code, and date. The Calculator Data report will provide the user with the data associated with the saved calculator. The report will provide the patient name and account number, plus all the fields from the Calculator module.

The report will be set up to print the calculator data for each account on a separate page. Refund Requests that do not allow printing need to be handled differently, such as submitted through an online Payer System. In these cases, the user needs a report that will provide them with the necessary information to enter the data into these systems. To accomplish this, the Remittance Report was created which will list only refunds that do not get checks issued.

This report will have the following fields: provider, provider number, patient, policy number, ICN, admin date, discharge date, payment date, payment amount, refund amount, and reason for refund. The Refund Worksheet will display all refunds for a particular payer on a patient account with the amounts being totaled to provide an overall refund amount. Each refund worksheet will be printed on a separate page when printed.

The reports module preferably also generates reports customized for use by managers. When a manager enters the managerial report section of the system of the present invention, they preferably have the option of selecting a managerial report to view. The manger can then click a continue button to be directed to a page with detailed report options.

The detailed options depend on the type of report selected, such as. Productivity Summary Report will allow for date ranges, and New Accounts Report will allow for provider selections and date ranges. If a manager is viewing the Audit Reports, there will be an additional search field that will list the associated users for the manager in a list box.

The manager can then select several users from the list along with the other search fields to generate a report. The manager can then click the submit button, this will submit the information to the Report Module, which will process the request and return the applicable report.

The Aging by Status report will group the accounts by their current status and the aging status time periods. The aging status time periods are preferably , , , , , and over days. For each current status time period there are preferably listed the number of accounts contained in the time period and their total dollar amount. The aging date is preferably based on the current date to discharge date.

The Time to Resolve Credits report will list only audited accounts. The report will list the patient name, account number, account balance, audited date, last credit transaction and calculated number of days to resolve.

The days to resolve would be based on the audited date to the last credit transaction. The report would be sorted by account balance, highest to lowest, then patient name. At the bottom of the report will be the average number of days required to resolve accounts. If one of these reports is selected, the manager will preferably be directed to a page that will have a drop down menu of the providers associated with their account.

The manager can select a provider, then click a continue button. The manager is then preferably directed to a form to refine their report options with the following fields: payer, line of business, begin date, end date, check number, type of recovery, reporting status, and invoice number. The payer field will be a drop down menu populated with payers associated with the selected provider. The line of businesses will be a drop down menu populated with LOBs associated with the payer.

After the manager has refined their search, the manager will click the build report button. The Refund Reports by Payer will preferably be the same report that is currently used in the Data Export module. The Retraction Request Form will preferably list patient information, insurance information, and adjustment information.

When the report is printed, each patient record will be printed on a separate page. The Detail Invoice Report will preferably be broken down by payer and line of business with each invoice printing on a separate page.

The Invoice can display the payer, LOB, invoice number, and date. Then, each refund will list separate line items with the provider name, ICN, patient name, account number, admin date, refund amount, and the fee payable to the entity that administers the system of the present invention.

It is preferred that only managers will have access to the Profit Reports. When the manager enters the Profit Report section there will preferably be a search form with Provider, a date range entry mechanism similar to that described for general reports, and Report Type fields.

The Provider field will preferably list providers associated with the manager. The Debit Balance Created report can show audited accounts where the audited balance is greater than zero. This report will preferably have the same fields as the Possible Errors report that is listed under the Audit Reports section.

The Allowances Posted report will preferably have the same fields as the Transaction Report that is listed under the Audit Reports section but will only display those audit transactions selected by a manager. The reports module of the present invention preferably includes the ability to generate Admin Reports. It is preferred that only administrators will have access to these reports. Two types of reports are preferably built into the system for use as Admin Reports.

When the administrator enters the Admin Report section, they will preferably be provided with a drop down menu type of data entry system for selecting what sort of report to view. The administrator can then click the appropriate icons to direct the administrator to the appropriate search form for the selected report. The System Reports Usage preferably displays the provider, user, report, and the number of times used. The report can be generated using a search criterion that the administrator will be able to select.

The search form may have the following fields: provider, user, report type, begin date, and end date. The provider and user fields may also incorporate drop down menus populated with the providers and users that are associated with the administrator respectively. The report type is preferably a drop down menu containing all the reports in the CDR Auditing System.

Once the administrator has selected the search criteria, they can click the build report button, which will open a pop-up window with the desired report displayed therein. The System Account Access report preferably provides administrators with information regarding users accessing patient accounts.

There can be a search form that the administrator will be able to use to build the criterion for the report. The fields are preferably: provider, user, patient last name, account number, begin date, and end date. The provider and user fields will be drop down menus with the providers and users associated with the administrator being listed. The remaining fields can be text fields to allow the administrator to enter a patient last name, account number, or date range.

After the administrator has selected the search criteria, they can preferably click the build report button, which can open a pop-up window with the report being displayed. The report may provide the following information: provider name, user, patient name, account number, and the access dates.

The system of the present invention preferably includes a Medicare Management module that allows hospitals to streamline their compliance procedures. The Medicare Management module allows entities that use the system of the present invention to reduce and manage the risks associated with maintaining compliance with Medicare's credit balance regulations. Medicare requires hospitals to report Medicare credit balances quarterly and to develop and maintain documentation which shows that each patient record was reviewed to determine if the credit balance is attributable to Medicare.

For simplicity, the specification generally refers to the current form required by Medicare i. However, portions of the specification as well as the claims refer to the required report as a Medicare Refund Compliance Form. Those of ordinary skill in the art will appreciate from this disclosure that the term Medicare Refund Compliance Form refers to the HCFA Form or any later form s developed by Medicare for reporting credit balances. The Medicare Management module of the present invention provides the first automated tool that is available to hospitals today to assist in meeting and managing the Medicare credit balance reporting requirements.

The Medicare Management module of the present invention enables multiple techniques to be used to manage Medicare credit balance accounts. This tool analyzes outstanding payments on each account to determine if a potential liability to Medicare exists.

The Medicare Management module preferably places a Medicare identifier on each account that is used in the Medicare Workload Estimate and user account assignment, as well as Management Reporting. When a Medicare account is identified and determined to represent a payment due to Medicare, the Refund Tracker function records and follows the manipulation of the account from identification through the reporting to Medicare and through the transfer of funds to Medicare.

The Medicare Management module of the present invention provides a clear systematic audit trail of identified Medicare refunds for hospitals that was never available before. Every hospital is required to submit quarterly reports to HCFA, the agency that monitors Medicare credit balances, detailing all of the Medicare overpayments identified by the hospital. The Medicare Management module preferably includes an alert function that automatically notifies a hospital officer via email 30 days prior to the due date of the report.

The notification preferably includes a calculation showing the estimated manpower necessary to analyze each account. The Medicare Management module notifies the officer again seven days before the due date if the report has not yet been submitted. The Medicare Management module preferably alerts managers at the end of each calendar quarter and one week before the day deadline for submitting the report. In addition to the above described email alerts, another alert will preferably occur when managers login to the System of the present invention.

Each time a manager logs in, the date will be checked to determine if it is within the day grace period of a new quarter. If it is, then the system will check to see if the corresponding Form has been submitted for the previous quarter. If the form has not been submitted, the manager will receive a pop-up alert upon initial login and an alert notice will be displayed on the main entry page throughout the manager's session.

In addition to providing reminders to hospital officers, the Medicare Management module can preferably automatically complete the HCFA Form by identifying all accounts managed by the system of the present invention and listing any audited accounts that have payments due back to Medicare.

The Medicare Management module also takes advantage of its integrated systems to provide the value codes required by Medicare on the HCFA The value codes are generated by translating the refund explanations discussed above in connection with the automated hospital forms to the HCFA reason and value codes required by Medicare. Once a report is submitted to Medicare it is preferably locked out so that changes to the report cannot be made afterwards.

The retention of actual copies of prior reports greatly simplifies compliance procedures for any future audit requirements. The Medicare Management module preferably allows managers to update and print out interim reports detailing Medicare refunds. When the manager enters the Medicare Refund Tracker function, he or she is preferably presented with a search form.

The form is preferably configured to receive search criteria via a drop down menu system. However, any method of entering the search criteria can be used without departing from the present invention.

Some of the criteria that can be used is: the providers that are associated with the manager; a date range; refund status, either non-submitted or submitted; or the like.

The manager can then submit the completed search form and the Refund Tracker function searches the database to return the Medicare refunds that match the criteria. The date range search will preferably be based on when the refund was batched, not the submitted date. This is important because the refunds that are used on the Form are based on refunds batched during the calendar quarter.

A manager will still be able to retrieve Medicare refunds from other quarters that have not been completely processed, but any updates will not alter the Form that was submitted. For each identified Medicare refund, the system will preferably display the following information: patient name, policy number, admit date, payment date, payment amount, and refund amount.

If the selected refund status was non-submitted refunds, then next to each record will be a set of checkboxes. One will be for submitted refunds and the other for the refund fulfilled. This will allow for managers to update multiple Medicare refunds at one time. If the manager wants to view the refund details on a particular patient listed, the patient name is preferably linked to allow the adjuster to view detailed information on the selected refund.

The refund detail page will preferably have the patient name, policy number, provider name, provider number, ICN, admit date, discharge date, payment date, payment amount, refund amount, and refund reason. The adjuster can select the appropriate boxes then click the submit button. The information will be saved and the adjuster will be returned to the refund details page.

To return to the search results page, the user will be able to click the back to results button. If a refund has been entered into the Medicare terminal, then the manager will check the submitted checkbox for that record.

If a check has been sent for the refund, or if Medicare has deducted the overpayment from a remittance advice, then the refund fulfilled checkbox can be selected. If this checkbox is selected and the submitted checkbox has not been checked, the submitted checkbox will be automatically checked. Once all applicable refunds have been checked, the manager will click the submit button. This will update the appropriate Medicare refunds, and then return the manager to the search results page, with the selected refunds no longer present.

If the refund status selected was submitted refunds, then only refund fulfilled checkboxes will be available to the managers. The managers will preferably also be able to print a report provided by the Medicare Refund Tracker function by clicking the print icon or the like. This will cause a pop-up window to open with the appropriate Tracker report, without checkboxes, to be displayed.

This will allow the form to be printer friendly. To print the form, the manager can use the browser print function. As detailed above the Medicare Management module preferably allows the manager to prepare and process the Medicare Form When the manager enters the section for Medicare Form , there will is preferably a drop down menu of providers associated with the manager and a drop down menu for choosing a calendar quarter and year that will be used to retrieve the Form The drop down for quarter and year will be populated based on the date that the selected provider's account was created.

This will allow managers to retrieve Form s whether the form has been submitted or not. There is a field to the Medicare Form search form that is a drop down menu with Inpatient and Outpatient options.

To start, the manager will need to select the type of Medicare Form that is to be viewed or edited. When the manager clicks the search button, the database will be checked to determine if Medicare Form has been submitted or not.

A submitted Medicare Form will retrieve the appropriate data from the database. A non-submitted Medicare Form will compare the provider account types to the patient account types and return the appropriate information to allow the manager to edit Medicare Form If the form does not exist in the database, then that calendar quarter has not had a Form filled out and submitted to Medicare.

This will result in the managers being directed to a Form with the applicable information entered and the managers will have the ability to edit various fields for each record.

This form would preferably be for the most recent quarter that a Form was not submitted and that has Medicare refund data. The Form has standard fields that must be entered and there are two fields that preferably have the proper option automatically selected based on posted refund information. Because this form will be tied into the system of the present invention, many of the fields will be automatically populated and cannot be edited. Below is a preferred list of fields on the form and whether the field can preferably be edited.

Provider Name—Pulled from the System of the present invention. Provider Number—This will be a form field for the manager to enter a value. Quarter Ending—This will be based on the quarter selected from the previous page. Page Number—Automatically generated based on the current page and total number of pages. Contact Person—This will be a form field for the manager to enter a value.

Defaults to name of manager. Phone Number—This will be a form field for the manager to enter a value. Defaults to phone number of manager. Beneficiary Name—Pulled from the System of the present invention, the patient name.

Type of Bill—This will be a drop down menu with a list of three-digit numbers to indicate the type of billing. The numbers will be standardized for this form. Admission Date—Pulled from the System of the present invention, the admit date. Discharge Date—Pulled from the System of the present invention, the discharge date. Paid Date—Pulled from the System of the present invention, the payment date.

Cost Report—Pulled from the System of the present invention, based on admit date to end of quarter. Amount of Credit Balance—Pulled from System of the present invention, refund amount. Amount Repaid—This will be a form field for the manager to enter payment amount being submitted with the submission of Form Reason for Credit Balance—will be a drop down menu with the following numbers 1, 2, and 3. The number corresponding to the note reference primary code will automatically be selected.

Value Code—will be a drop down menu displaying the available two digit codes, which currently are 12, 13, 14, 15, 16, 41, 42, and If the note reference selected for the refund transaction has the value code entered, then the corresponding value code will be selected. There will also be a blank option if no code should be selected or if the note reference value code does not match the current list of value codes.

At the bottom of the form there are preferably three functions that can be selected to update, print, and submit the form. If the manager clicks the update function, the form will be validated. The validation of the form preferably consists of checking the updated provider number, contact person, phone number, and amount repaid being entered, and calculation check of the Medicare Amount Outstanding. If any of these checks fail, the manager will be alerted with the option to submit the update or cancel the update to correct the potential error.

If the manager selects to submit the updates with potential errors, the data will be saved to the database and the manager will be returned to the form.

If the manager selects to print the form, a pop-up window will preferably open with the form being displayed without the editing features. If the manager has completed filling out the form and is ready to submit the form to Medicare, the manager can select the submit function.

The manager will receive an alert once a form is submitted indicating that the form can no longer be edited. Once the manager acknowledges this alert the form will be validated. If errors are still present at this time, the form will not be processed. If the validation is successful, the form will be saved to the database and marked as submitted.

The manager will preferably then be directed to the form with no editing features and a pop-up window will open with the Report Certification letter and Form being displayed. The manager can then print the report for submission to Medicare. Under the Management Reports module, there are two reports which are specific to the Medicare process.

The preferred payer insurance companies software enables the electronic identification, recordation, posting and reporting of retracted claims between providers health care facilities and payers insurance companies. Typically, the provider and the payer systems use different fields. To facilitate communication between the two systems, the claim retraction system acts as a bridge between the two systems. The automatic claim identification module is explained in conjunction with the flow chart of FIG.

The reporting module allows, if all the claim data is available, for an automatic reporting of overpayments to payers. However, if lesser claim data is available, the module allows for a partial automation of the reporting of overpayments. The overpayments reporting can be divided into four scenarios reflecting the available claim data.

In scenario one, the provider and payer claim data is available to the module allowing for a highest level of automation. In a second scenario, the provider data is available to the system and the payer data is not available. In a third scenario, the payer data is available and the provider data is not available. In a fourth scenario, neither the payer or provider data is available. For scenario one both provider and payer data is available , steps , , a link is created between the provider and payer data.

When an adjuster provider user processes a refund, step an automatic search for the matching claim within the payer claim data is performed step If an exact matching record is found, step the overpaid claim is reported to the payer, step The adjuster can select one of the potential matching claims and report the overpaid claim to the payer step , , , If the adjuster does not find a match using the initial search results, the adjuster can use a custom search screen, step In the preferred implementation, the fields are initially filled with the information retrieved from the Provider refund record.

This filled information can be modified by the searcher, step If the search results in the correct claim being discovered, step , the overpaid claim is reported to the payer. If the adjuster is not able to find the correct claim, step , a new claim record is automatically created using the provider refund data, step This created record is reported to the payer.

In scenario two provider data but no payer data , step , a new overpaid claim record is automatically created using the provider refund data, step In scenario three no provider data but payer data , the adjuster searches the payer paid claims file and manually selects the correct claim to report to the payer.

The adjuster uses a custom search screen. If the correct claim is discovered, the overpaid claim is automatically reported to the payer. If the correct claim is not found, the adjuster enters the data into a newly created overpaid claim report to be submitted to the payer. In scenario four no payer or provider data , the adjuster enters the data required to create the new claim report. The module also allows the payer to review each claim to determine whether all necessary data elements for the retraction are present.

If additional information is required by the Payer, the module preferably sends the provider adjuster a message requesting the additional information. The provider can send the requested information to the payer via the module.

Once an overpaid account has been identified by the provider via the account analysis module, if the payer is subscribed to the system, the overpaid account information is sent to the payer in an automated manner, step Preferably, the information submitted to the payer via the module includes date reported, patient name, hospital account number, payer claim number, refund amount and a reason for the over payment.

After the payer user reviews the information for an overpaid account, the user can place an indicator of the status of the account. The adjuster for the account of the provider can review the status indicator of the account via the system at any time.

For an account requiring additional information prior to retraction, step , the payer user sends a text message to the provider adjuster detailing the information request, steps , Preferably, these messages are provided to the user at sign in to the system.

When the user signs in, the claims requiring information by the payer are displayed. The adjuster can select a claim and the detailed information of the claim and the text message. The adjuster, after gathering the requested information, sends a text message to the payer user detailing the requested information, steps , The adjuster is preferably only permitted by the system to change the status only when the reply message is entered.

Each payer user is provided with a list of claims that the requested information was sent. This list is preferably available the payer user at sign in. The payer user can select an account from the list and view the detailed information and the text message sent by the adjuster. The user canceling the attempted retraction is required to provide a text message explaining the cancellation. If the claim was cancelled by a payer user, the corresponding provider user is sent the message.

If the claim was cancelled by a provider user, the corresponding payer user is sent the message. That user is provided with a list of the cancelled accounts, preferably at sign in. The user can select a cancelled account and view the account's detailed information and the cancellation text message.

The payer workload management module allows for a payer manager to assign overpayment accounts to payer user in an efficient manner. Workload management is described in conjunction with the flow chart of FIG.

A user assignment screen is displayed to the manager. The assignment screen has a field allowing the manager to select a particular provider health care facility or all providers, step , preferably by a pull-down menu. The default entry is preferably all providers. Based on the selected provider s , the total number of overpaid accounts for the provider s , a list of unassigned accounts, and a list of payer users associated with the provider s is displayed.

Also, displayed for each user is a number of accounts currently assigned to that user. If a particular provider is selected, each payer user assignment of that provider is editable, preferably by executing an edit icon by the manager. For each user, a user detail page can be displayed showing the total number of accounts assigned to the user and a listing of providers with the user assignment details and account numbers for each provider.

Edit icons are preferably displayed next to each provider so that the manager can edit the user assignment. When the manager edits a user assignment, step , an assignment entry page is displayed, step The entry page preferably displays the payer user's name, the provider name, a quick fill button for profit maximizer and assignment variable fields. The profit maximizer button assigns accounts as to maximize the payer's profit.

The accounts are assigned in an order based on their business group, line of business and whether or not the groups are self insured. To illustrate, one group serviced by the payer may be self insured and the other group may not be self insured. The resolution of the account for the self insured group is passed onto that group and it does not impact the payer's bottom line.

However, resolution of accounts for the non-self insured group improves the payer's bottom line and resolving these accounts first improves the payer's profits. The profit maximizer assigns accounts to users having an allowance error scoring indicators 2 , 4 , 6 and 9 first. Retracting these accounts tends to increase the payer's profit.

The assignment variables are broken down into three columns. Preferably, five rows are provided on the entry page, with a link provided to add five additional rows. The first column allows the manager to select a field to be queried, step , preferably selected by a pull-down window. The selectable fields are: patient name first character of last name , submission date, line of business, provider and group number. The next second column is for the operator: greater than, greater than or equal to, equal to, less than and less than or equal to, step The last third column is for a query value, step The type of field being queried determines the allowed query values for the third column.

After the assignment variable fields are filled, the system verifies that the information in each row is in the proper data format, step If it is not, an error message is generated, step By executing a test button by the manager, a number of accounts the query results in is displayed, step If the check fails, the manager is provided a reason for the failure. If the save button is executed without the test being previously executed, the system performs the test and results checking automatically.

The saved results are saved to a file and the applicable accounts are updated with the payer user identification ID , step After one payer user assignment is completed, the manager can proceed to assign accounts to another user, step As the overpaid account data for an account is provided, the system checks the user assignment for the account.

If the account matches a user assignment, it is automatically assigned to the user. The payer management module enables the providers healthcare facilities and payers insurance companies to access and prepare numerous reports and forms. These reports and forms include refund reports by payer, detail invoice reports and retraction request forms.

The module also allows for the creation and storage of custom reports. The payer manager selects a report or form to be prepared. A provider is selected by the manager, preferably by a pull-down menu.

A screen for refining search options is displayed to the manager. A System Audit is an account that is identified by a CDR user non-health care user for auditing and a System Reporting is an account identified by a health care facility user. The Begin and End Date fields are filled with a date or range of dates. The Check Number and Invoice Number fields are filled with a corresponding numeric value or range.

The generated report is subsequently displayed to the manager. The manager can print the report or export it to a data file. The provider user is provided with a display screen having search fields, step , including ICN, last name, first name, recipient ID and account number. To perform a search if the payer's data is on the system, step , either at least the ICN or at least two of the other fields must be used. After the search criteria is entered, step , the search criteria is checked to see if at least the ICN or two other criteria is included.

If the check fails, an error message is displayed. Otherwise, the claims database is queried using the search criteria and the provider numbers associated with the Provider user ID. The results of the search are displayed, step Preferably, the results are displayed as last name, first name, account number, recipient ID, from date of service, payment date and payment amount.

The results are also preferably ordered by last name, then by first name and then by from date of service. If no results are returned, the user can try different criteria, step A specified number of the results are displayed on a screen. If the results exceed this number, a list of screens is provided the user to navigate through the results. For each record, a report can be viewed or printed by executing a corresponding icon. A detailed claim report is displayed, preferably without graphics to aid in printing.

The displayed report includes: last name, first name, account number, recipient ID, ICN, claim status, claim total charges, claim non-coverage charges, claim deductible, claim coinsurance, claim contractual, payer name and provider name. The report can be printed by executing a corresponding print button. For each record displayed in the search results, the provider user can select the claim for retraction, step , Once the correct claim is identified, the user is given the option, step , of printing a copy of the paid claim information in the form of a recreated EOB, step The selection can be performed from the displayed search results or from the displayed claim report details.

Selecting the claim retrieves a claim retraction form. If the provider user can not find a desired claim in a search, the user can manually enter a new claim.

The claim information that was on the search page results is preferably displayed on the top of the screen along with the retraction form. The fields in the retraction form are reason for refund, refund amount, COB insurance name, COB insurance number and additional information. The reason for refund is preferably populated by a pull-down menu with notes from the notes reference database. The refund amount is automatically populated with the claim payment amount.

The provider enters the information of the other fields. The retraction can be submitted using a corresponding retraction button.

After executing the corresponding retraction button, the retraction form is checked to ensure that the reason for refund and refund amount fields are complete and the refund amount is not greater than the claim payment amount. If the check fails, an error message is displayed with the reason for the error. For all submitted retractions, the manager is provided a list, preferably by email. The email confirms the submission of the retractions along with information for each retraction.

The retraction information includes status, submission ID, ICN, refund amount, reason for refund, provider name and payer name. The flowchart shown in FIG. During step , the accounts are evaluated using at least one of the standard score module and the ASM. After the account transactions have been evaluated, the process patient refunds module can be used during step Once the scoring of selected accounts is completed the process patient refunds module may automatically post the corrected transactions within the system and generate the files necessary to automatically disperse the checks to the associated patients.

Then, a misposted payment transfer module described below can be used in step During step , a Misposted adjustment module described below can be used.

While the system shown in FIG. It is preferred that access to the module is not permitted for non subscribers. This resolution indicates that the patient has made an overpayment to the account and that the money cannot be transferred to any other open dates of service.

Next, in step , the guarantor's address is verified to validate that the street address, city, state and zip code fields are all populated and do not contain any null or invalid data e.

If the guarantor's address is invalid, the account is preferably disqualified from processing and the process patient refunds module moves to the next account during step If the selected account has a valid guarantor address, then, during step , the process patient refunds module checks whether the first patient payment from the account is greater than or equal to the account balance.

During step , the process patient refunds module posts a refund transaction to an audit detail table indicating the account was resolved through a patient refund. Below is a preferred list of fields of the transaction table:. If so, the system moves to the next account during step Once the patient refund module has looped through all of the accounts within the record set and audited the accounts that could be resolved, the system will then bundle the transactions together for tracking purposes.

Once this record has been created, all accounts in the batch will be updated with the unique ID of the newly created batch, step During step , a file of the transactions is produced that can be uploaded into a Hospitals patient accounting system the file can be designed for use with any other desired accounting system.

Rules templates can be established for each Provider for the patient refund module to retrieve prior to export to ensure that the file is in the proper format and properly named for the receiving institution. Once the file has been created, it can be encrypted using PGP or any other known encryption method and FTP'd or transmitted using any other known file transfer method or protocol to the Provider, step The encryption keys and the FTP instructions can be customized for each provider if desired.

The proper encryption keys and file transfer instructions for each Provider can be stored with the rules regarding file format for the Provider's accounting system. After the file is transferred to the Provider, the patient refund module can create a summary report of the accounts that were resolved through the patient refund module, step Company Trademark Status Update Alerts are email updates of the latest trademarks' status change on company level.

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