System for Processing Retail Clinic Claims

Abstract

A method for electronically determining patient medical treatment eligibility, coverage, copayment amount and insurer billing, by: (a) a patient requesting medical treatment at a retail clinic; (b) the patient presenting a health insurance card at the retail clinic; (c) the retail clinic transmitting patient health insurance card information to a centralized adjudication facility; (d) the retail clinic transmitting medical treatment information to the centralized adjudication facility; (e) the centralized adjudication facility determining patient medical treatment coverage, eligibility and copayment amount (f) transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic; (g) the patient purchasing the medical treatment by paying the retail clinic the copayment amount, (h) transmitting a bill to the health care insurance provider; and (i) thereby informing the retail clinic clinician to sell the medical treatment to the patient. By simultaneously billing the patient and the insurer, the present invention provides a system that processes the sale of the medical treatment as a sales transaction.

1 . A method for dispensing a medical treatment to a patient while determining patient medical treatment coverage, eligibility, copayment amount and insurer cost, comprising the steps of
 (a) a patient requesting a medical treatment at a retail clinic;   (b) the patient presenting a health insurance card at the retail clinic;   (c) the retail clinic transmitting health insurance card information to a centralized adjudication facility;   (d) the retail clinic transmitting patient medical treatment information to the centralized adjudication facility;   (e) the centralized adjudication facility determining patient medical treatment coverage, eligibility and copayment amount;   (f) transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic;   (g) the patient purchasing the medical treatment by paying the retail clinic the copayment amount;   (h) transmitting a bill to the health care insurance provider; and   (i) thereby informing the retail clinic clinician to sell the medical treatment to the patient.   
     
     
         2 . The method of  claim 1 , wherein the health insurance card information is transmitted from the retail clinic to the centralized adjudication facility over an NCPDP retail clinic system. 
     
     
         3 . The method of  claim 1 , wherein the patient medical treatment information is transmitted from the retail clinic to the centralized adjudication facility over an NCPDP retail clinic system. 
     
     
         4 . The method of  claim 1 , wherein the patient medical treatment coverage, eligibility and copayment amount are transmitted from the centralized adjudication facility to the retail clinic over an NCPDP network. 
     
     
         5 . The method of  claim 2 ,  3  or  4 , wherein the NCPDP retail clinic system is NCPDP standard messaging. 
     
     
         6 . The method of  claim 2 ,  3  or  4 , wherein the NCPDP retail clinic system is an Internet enabled web interface. 
     
     
         7 . The method of  claim 1 , wherein the centralized adjudication facility determines the patient medical treatment coverage and eligibility by identifying the patient on a patient information database. 
     
     
         8 . The method of  claim 7 , wherein the centralized adjudication facility determines the patient copayment amount by:
 (i) identifying the medical treatment on a medical treatment database; and then   (ii) identifying the patient copayment amount for the medical treatment.   
     
     
         9 . The method of  claim 8 , wherein identifying the patient copayment amount for the medical treatment comprises comparing the patient information database to the medical treatment database to determine the patient copayment amount that corresponds to the patient's heath plan coverage. 
     
     
         10 . The method of  claim 1 , wherein the health insurance card is a financial card. 
     
     
         11 . The method of  claim 10 , wherein the financial card is a credit or debit card. 
     
     
         12 . The method of  claim 10 , wherein the financial card is any of a VISA™, Master Card™, American Express™ or Discover™ card. 
     
     
         13 . The method of  claim 10 , wherein the retail clinic transmitting health insurance card information to a centralized adjudication facility comprises transmitting a financial card number to the centralized adjudication facility. 
     
     
         14 . The method of  claim 10 , wherein the retail clinic transmitting health insurance card information to a centralized adjudication facility comprises:
 (i) transmitting a financial card number from the retail clinic to a financial clearing house;   (ii) generating a claim for adjudication at the financial clearing house; and then   (iii) transmitting the claim for adjudication from the financial clearing house to the centralized adjudication facility.   
     
     
         15 . The method of  claim 13  or  14 , wherein the financial card number is transmitted over a financial card network. 
     
     
         16 . The method of  claim 13  or  14 , wherein the centralized adjudication facility identifies the patient by the patient's financial card number. 
     
     
         17 . The method of  claim 10 , wherein the patient purchases the medical treatment with the financial card. 
     
     
         18 . The method of  claim 10 , wherein the patient medical treatment coverage, eligibility and copayment amount are directly transmitted from the centralized adjudication facility to the retail clinic. 
     
     
         19 . The method of  claim 10 , wherein the patient copayment amount is transmitted from the centralized adjudication facility to a financial clearing house, and then from the financial clearing house to the retail clinic. 
     
     
         20 . The method of  claim 1 , wherein transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic comprises displaying the cost of payment by the patient for the medical treatment on a retail clinic computer screen. 
     
     
         21 . The method of  claim 1 , further comprising:
 (h) the centralized adjudication facility billing the patient's insurer.   
     
     
         22 . The method of  claim 21 , wherein the health care insurance provider is billed an amount equal to a value of the medical treatment less the patient copayment amount. 
     
     
         23 . The method of  claim 21 , further comprising:
 (i) the centralized adjudication facility paying the retail clinic for the medical treatment purchased by the patient.   
     
     
         24 . The method of step  1 , wherein the patient purchasing the medical treatment further comprises:
 (i) the centralized adjudication facility recommending a substitute medical treatment for the patient; and   (ii) the patient purchasing the substitute medical treatment.   
     
     
         25 . A system for dispensing a medical treatment to a patient while determining patient medical treatment coverage, eligibility, copayment amount and insurer cost, comprising:
 (a) a retail clinic;   (b) a centralized adjudication facility;   (c) a communication system for transmitting health insurance card information and patient medical treatment information from the retail clinic to the centralized adjudication facility;   (d) a computerized benefits analysis system in the centralized adjudication facility for determining patient medical treatment coverage, eligibility and copayment amount;   (e) a communication system for transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic; and   (g) a computerized purchasing system in the retail outlet for selling the medical treatment to the patient.   
     
     
         26 . The system of  claim 25 , wherein the communication system for transmitting health insurance card information and patient medical treatment information from the retail clinic to the centralized adjudication facility is an NCPDP network. 
     
     
         27 . The system of  claim 25 , wherein the communication system for transmitting the patient medical treatment coverage, eligibility and copayment amount from the centralized adjudication facility to the retail clinic is an NCPDP network. 
     
     
         28 . The system of  claim 26  or  27 , wherein the NCPDP network is an NCPDP standard messaging network. 
     
     
         29 . The system of  claim 26  or  27 , wherein the NCPDP network is an Internet web interface network. 
     
     
         30 . The system of  claim 25 , wherein the health insurance card is a financial card. 
     
     
         31 . The system of  claim 30 , wherein the financial card is a credit or debit card. 
     
     
         32 . The system of  claim 31 , wherein the financial card is any of a VISA™, Master Card™, American Express™ or Discover™ card. 
     
     
         33 . The system of  claim 25 , further comprising:
 (h) a computerized communication system in the centralized adjudication facility for billing the patient's insurer.   
     
     
         34 . The system of  claim 25 , further comprising:
 (h) a computerized system in the centralized adjudication facility for recommending a substitute medical treatment for the patient.