SYSTEM AND METHOD FOR FORECASTING PAYMENTS OF HEALTHCARE CLAIMS

摘要

Systems and methods are provided for forecasting remittances of a target claim filed for reimbursement of a healthcare service provided to an insured patient. A set of data associated with the target claim is extracted from a database. A claim value engine queries the database using the set of data, and based on the query, selects a plurality of claims from the database that are associated with the service provider and the claim payer of the target claim, are older than the target claim by at least a predetermined period of time, and have a previous remittance status similar to that of the target claim. The claim value engine also evaluates a mean expectation value for a predetermined date based on the reimbursement amounts for the selected plurality of claims, and determines a net reimbursement of the target claim by multiplying the evaluated mean expectation value by the claim amount.

主权项

1. A method for forecasting remittances of a target claim filed for reimbursement of a healthcare service provided to an insured patient, the method comprising:
determining, using a data extraction module running on a processor, a set of data associated with the target claim, the set of data including a service provider, a claim payer, a claim amount, an age, and a remittance status; querying, using a claim value engine running on the processor, a database using the set of data associated with the target claim; based on said querying, selecting, using the claim value engine, a plurality of claims stored in the database that (i) are associated with the service provider and the claim payer of the target claim, (ii) are older than the target claim by at least a predetermined period of time, and (iii) have a previous remittance status, from when the selected plurality of claims were the age of the target claim, that is the same as the remittance status of the target claim, wherein each of the selected plurality of claims has a claim amount, a plurality of reimbursement amounts, and a plurality of corresponding reimbursement dates; evaluating, using the claim value engine, a mean expectation value for a predetermined date based on the plurality of reimbursement amounts of the plurality of claims; and determining, using the claim value engine, a reimbursement value of the target claim that is to be received by the predetermined date by multiplying the evaluated mean expectation value by the claim amount.