Direct connectivity system for healthcare administrative transactions

Abstract

A direct connectivity system provides automated healthcare administrative transaction submission, including claim submission, eligibility verification and claim status, from healthcare service providers directly to payers. The direct connectivity system bypasses transaction processing intermediaries such as clearinghouses by directly connecting providers to payers in a many to many manner. Existing single payer web portals are supplanted by a many to many network that has a common interface across multiple payers. The direct connectivity system may receive responses directly from payers and may prepare or process the responses for a practice management program so that the service provider receives rapid feedback on the administrative transaction submission. The direct connectivity system may automatically analyze transaction file attributes to determine one or more of many payers to which to send a transaction file, from one of many providers. Batch and singleton file transfer is supported for multiple file formats, optionally with secure file transfer.

1 . A service provider data processing system comprising:
 a communication interface;   a memory comprising:
 transaction files; 
 transaction file configuration data comprising configuration entries that associate transaction file attributes with multiple payers; 
 payer connection data comprising payer communication addresses for the multiple payers; and 
 a transaction file submission program comprising transaction file attribute analysis instructions that determine a selected payer communication address in the payer connection data for an analyzed transaction file of the transaction files, and transmission instructions that initiate transfer of the analyzed transaction file to the selected payer communication address through the communication interface, thereby bypassing transaction file processing intermediaries; and 
   a processor coupled to the memory that executes the transaction file submission program.   
     
     
         2 . The service provider data processing system of  claim 1 , wherein the memory further comprises a response acceptance program comprising:
 response reception instructions that receive a response to the transfer of the analyzed transaction file from the selected payer communication address; and   response push instructions that configure the response for a practice management program in the service provider data processing system.   
     
     
         3 . The service provider data processing system of  claim 1 , wherein the transaction file configuration entries comprise a filename entry and a payer identification entry. 
     
     
         4 . The service provider data processing system of  claim 1 , wherein the transaction file configuration entries comprise a directory entry and a payer identification entry. 
     
     
         5 . The service provider data processing system of  claim 1 , wherein the payer connection data comprises payer identification entries associated with the payer communication addresses. 
     
     
         6 . The service provider data processing system of  claim 1 , further comprising an extensible markup language (XML) wrapper program that applies an XML wrapper to at least a portion of the analyzed transaction file. 
     
     
         7 . The service provider data processing system of  claim 1 , further comprising an encryption program that applies an encryption to the analyzed transaction file. 
     
     
         8 . The service provider data processing system of  claim 1 , wherein the memory further comprises a practice management program and wherein the transaction file submission program is integrated with the practice management program through a transaction submission program application programming interface. 
     
     
         9 . The service provider data processing system of  claim 8 , wherein the practice management program is a physician's office management and medical information system (POMIS) program. 
     
     
         10 . A direct connectivity gateway that interacts with a practice management processing system that prepares administrative transaction files, the gateway comprising:
 a communication interface;   a memory comprising:
 payer connection data comprising payer communication addresses for multiple payers; 
 a file interface program comprising file transfer instructions that transfer transaction files to the direct connectivity gateway; and 
 a transaction file submission program comprising transaction file attribute analysis instructions that determine a selected payer communication address in the payer connection data for an analyzed transaction file of the transaction files, and transmission instructions that initiate transfer of the analyzed transaction file to the selected payer communication address through the communication interface, thereby bypassing transaction file processing intermediaries; and 
 a processor that executes the transaction file submission program and the file interface program. 
   
     
     
         11 . The gateway of  claim 10 , wherein the communication interface is a service provider local network interface connected to the practice management processing system. 
     
     
         12 . The gateway of  claim 10 , wherein the transaction file attribute analysis instructions comprise filename attribute analysis instructions. 
     
     
         13 . The gateway of  claim 10 , wherein the transaction file attribute analysis instructions comprise directory attribute analysis instructions. 
     
     
         14 . The gateway of  claim 10 , further comprising an extensible markup language (XML) wrapper program that applies an XML wrapper to at least a portion of the analyzed transaction file. 
     
     
         15 . The gateway of  claim 10 , wherein the practice management processing system and the gateway are located at a service provider. 
     
     
         16 - 25 . (canceled) 
     
     
         26 . A non-transitory machine readable medium encoded with instructions that cause a service provider data processing system to perform a method comprising:
 determining, based on transaction file attribute analysis instructions, a selected payer communication address in payer connection data for an analyzed transaction file of a plurality of transaction files, wherein the payer connection data includes payer communication addresses for multiple payers; and   initiating transfer of the analyzed transaction file to the selected payer communication address through a communication interface, thereby bypassing transaction file processing intermediaries.   
     
     
         27 . The non-transitory machine readable medium of  claim 26 , further comprising:
 receiving a response from a selected payer associated with the selected payer communication address; and   automatically preparing the response for input by a practice management program.   
     
     
         28 . The non-transitory machine readable medium of  claim 39 , wherein switching comprises reading the payer connection data to associate the file attribute with the selected payer and initiating transmission of the analyzed transaction file. 
     
     
         29 - 38 . (canceled) 
     
     
         39 . The non-transitory machine readable medium of  claim 26 , further comprising:
 automatically monitoring a service provider memory for the analyzed transaction file prepared by a provider;   obtaining a file attribute of the analyzed transaction file; and   switching the analyzed transaction file directly from the provider to a selected payer associated with the selected payer communication address, according to the file attribute, by initiating the transfer of the analyzed transaction file to the selected payer communication address through the communication interface.   
     
     
         40 . The non-transitory machine readable medium of  claim 39 , further comprising:
 indexing the file attribute into attribute data comprising attribute identifiers associated with the multiple payers to determine the selected payer associated with the selected payer communication address.