Automated Pre-Admission Medical Insurance Eligibility and Coverage Verification

The cost of processing erroneous or incomplete medical care claims, or of non-reimbursed services due to incorrect, unknown or incomplete insurance information, represents a considerable out-of pocket expense for every health care provider. The proposed project will develop a system for providing health care providers with accurate and timely pre-admission verification of insurance eligibility and coverage, thereby significantly reducing these costs. The system architecture draws on software previously developed under DOD sponsorship for real time management of data in a distributed concurrent engineering environment. The implementation will be modular, esily capable of handling diverse data standards and communication protocols, scaleable, and cost effective for both the provider and the participating insurers. The proposed design addresses authentication and patient confidentiality issues and adheres to open standards for user interfacing and networking. Feasibility will be demonstrated in Phase I with prototype software tested in conjunction with a major primary care research and teaching hospital. A fully functional system, suitable for direct commercialization, will be developed and demonstrated in the user environment in Phase II. Anticipated Benefits: The proposed software will provide direct and immediate savings to health care providers by reducing errors and omissions in claim preparation and increasing their cost reimbursement rate. In addition, it provides a mechanism for insurers (including federal, state, and local government) to easily and cost-effectively make patient insurance coverage information available to providers, while retaining access control to their data.