US-20260127680-A1 - ELECTRONIC MEDICAL RECORDS SYSTEMS TRANSITIONS TO SUPPORT PENDING INSURANCE CLAIMS

US20260127680A1US 20260127680 A1US20260127680 A1US 20260127680A1US-20260127680-A1

Abstract

An automatic bulk insurance claims re-submission of pending insurance claims facilitates transitioning from one technical electronic medical record (EMR) system to another EMR system. The method involves extracting past insurance claims that remain pending due to non-submission or rejection by one or more payers for various reasons, classifying these as pending insurance claims. It further includes analyzing Electronic Remittance Advice (ERA) reconciliation data provided by the payer to identify discrepancies between expected and actual payments. The payment status and reasons behind non-payment for each pending claim are determined. Necessary modifications are then implemented to ensure that the claims meet approval criteria. Finally, the method automatically resubmits all modified pending claims in a single bulk upload, ensuring that all corrected claims are accurately reflected in the submission, and ensuring that the efficiency and accuracy of the insurance claim re-submission process are maintained, leading to improved reimbursement outcomes for healthcare providers.

Inventors

Anusha Tiwari
Manish Shukla

Assignees

Ocean Friends, Inc.

Dates

Publication Date: 20260507
Application Date: 20251105

Claims (20)

1 . A method of transitioning from one technical electronic medical record (EMR) system to another EMR system using automatic bulk re-submission of pending insurance claims, the method comprises: executing code by a computer system to enable transition from one EMR system to another EMR system by causing the computer system to perform operations comprising: uploading insurance medical records and insurance claims from a first electronic medical records system to the computer system to facilitate transitioning from the first electronic medical records system to a second electronic medical records system; extracting past insurance claims that were previously submitted and not fully paid by a payer due to at least one of a plurality of reasons including denial and rejection, wherein the previously submitted and unpaid insurance claims are classified as pending insurance claims; analyzing an Electronic Remittance Advice (ERA) reconciliation data provided by the payer for pending insurance claims, wherein the ERA data helps in identifying discrepancies in the pending insurance claims; identifying the payment status of each pending insurance claim and the reason behind non-payment of that pending insurance claim; implementing a set of modifications to each of the pending insurance claims to meet the necessary criteria for approval of the pending insurance claims upon bulk re-submission; automatically re-submitting the modified pending insurance claims to the payer in a single bulk upload, ensuring that all the corrected insurance claims are accurately reflected in the re-submitted insurance claims.
2 . The method of claim 1 wherein the at least one of a plurality of reasons due to which the payer reject the insurance claims includes inaccurate information, insurance expiration, the amount exceeding the threshold values, non-covered medical sessions, general errors, and incomplete information from users.
3 . The method of claim 1 wherein the ERAs provide detailed information about the payment, such as the amount paid, any adjustments made, and the reason codes.
4 . The method of claim 1 wherein the payment status of the identified pending insurance claims further includes: not paid due to inaccurate information, insurance expiration, the amount exceeding the threshold values, non-covered medical sessions, general errors, and incomplete information from users; and partially paid insurance claims due to non-covered medical sessions, and the amount exceeding the threshold values.
5 . The method of claim 1 wherein the errors and discrepancies due to which the insurance claim is pending and requires modifications are automatically detected and flagged based on the analyzed ERA reconciliation data.
6 . The method of claim 1 wherein the modifications needed for fixing the pending insurance claims include: updating documentation that supports the pending insurance claim, such as medical records, patient information, and treatment details; filling in any incomplete information blocks that are required for accurate insurance claim processing, such as personal details, patient identification, and insurance details; and correcting any errors and omissions found in the original insurance claim submission, such as incorrect patient data.
7 . The method of claim 1 further comprises: generating a report summarizing the status of all insurance claims, including pending claims, as well as the actions taken for reconciliation and re-submission.
8 . The method of claim 1 wherein the payer is an insurance company, provided with a unique ID code.
9 . The method of claim 1 further comprising: executing the code by the one or more processors to cause the computer system to perform further operations including notifying healthcare providers and users about the status of pending insurance claims, including notifications for insurance claims requiring immediate attention or additional documentation.
10 . A system for transitioning from one technical electronic medical record (EMR) system to another EMR system using automatic bulk re-submission of pending insurance claims, the system comprising: one or more processors of a computer system; and a memory, coupled to the one or more processors, that stores code and execution of the code by the one or more processors causes the computer system to perform operations comprising: uploading insurance medical records and insurance claims from a first electronic medical records system to the computer system to facilitate transitioning from the first electronic medical records system to a second electronic medical records system; extracting past insurance claims that were previously submitted and not fully paid by a payer due to at least one of a plurality of reasons including denial and rejection, wherein the previously submitted and unpaid insurance claims are classified as pending insurance claims; analyzing an Electronic Remittance Advice (ERA) reconciliation data provided by the payer for pending insurance claims, wherein the ERA data helps in identifying discrepancies in the pending insurance claims; identifying the payment status of each pending insurance claim and the reason behind non-payment of that pending insurance claim; implementing a set of modifications to each of the pending insurance claims to meet the necessary criteria for approval of the pending insurance claims upon bulk re-submission; and automatically re-submitting the modified pending insurance claims to the payer in a single bulk upload, ensuring that all the corrected insurance claims are accurately reflected in the re-submitted insurance claims.
11 . The system of claim 10 wherein the pending insurance claims are visible to the user or healthcare provider on a user interface integrated within the online billing platform.
12 . The system of claim 10 wherein the one or more databases store historical claim data, patient records, and documentation necessary for verifying and supporting insurance claims.
13 . The system of claim 10 wherein the analyzer utilizes machine learning algorithms to identify patterns in ERA reconciliation data, helping to predict potential issues in future claim submissions.
14 . The system of claim 10 wherein execution of the code by the one or more processors causes the computer system to perform further operations comprising: notifying healthcare providers and users about the status of pending insurance claims, including notifications for insurance claims requiring immediate attention or additional documentation.
15 . The system of claim 10 wherein the at least one of a plurality of reasons due to which the payer reject the insurance claims includes inaccurate information, insurance expiration, the amount exceeding the threshold values, non-covered medical sessions, general errors, and incomplete information from users.
16 . The system of claim 10 wherein the ERAs provide detailed information about the payment, such as the amount paid, any adjustments made, and the reason codes.
17 . The system of claim 10 wherein the payment status of the identified pending insurance claims further includes: not paid due to inaccurate information, insurance expiration, the amount exceeding the threshold values, non-covered medical sessions, general errors, and incomplete information from users; and partially paid insurance claims due to non-covered medical sessions, and the amount exceeding the threshold values.
18 . The system of claim 10 wherein the errors and discrepancies due to which the insurance claim is pending and requires modifications are automatically detected and flagged based on the analyzed ERA reconciliation data.
19 . The system of claim 10 wherein the modifications needed for fixing the pending insurance claims include: updating documentation that supports the pending insurance claim, such as medical records, patient information, and treatment details; filling in any incomplete information blocks that are required for accurate insurance claim processing, such as personal details, patient identification, and insurance details; and correcting any errors and omissions found in the original insurance claim submission, such as incorrect patient data.
20 . The system of claim 10 further comprises: generating a report summarizing the status of all insurance claims, including pending claims, as well as the actions taken for reconciliation and re-submission.

Description

CROSS-REFERENCE TO RELATED APPLICATION(S) This application claims the benefit under 35 U.S.C. § 119(e) and 37 C.F.R. § 1.78 of U.S. Provisional Application No. 63/716,721, which is incorporated by reference in its entirety. FIELD OF THE INVENTION The present invention generally relates to the field of electronics, and more specifically to the automatic re-submission of electronic medical records systems transitions to support pending insurance claims. BACKGROUND Health insurance claim forms are standard documents used by healthcare providers. They contain the necessary patient and treatment information and help request payment from health insurance companies. Health insurance claim forms are vital for billing and claims processing systems. The claim forms provide clear communication regarding medical services availed, the scope of the services, and the cost involved. Healthcare providers use them to get reimbursed accurately and promptly. For insurance companies, the data helps in fraud detection, claim processing, and reimbursements. Billing details are crucial for healthcare providers and insurance companies. The data ensures that healthcare providers are reimbursed correctly for their services, and insurance companies can use it to verify coverage and expedite reimbursement. Accurate financial information helps prevent billing errors and claim denials and facilitates smoother cash flow between all parties involved. Conventionally, the process of handling health insurance claims has several limitations. These methods do not include the analysis of Electronic Remittance Advice (ERA) data, which is essential for identifying discrepancies between expected and actual payments. As a result, claims that remain unpaid or are incorrectly processed often go unnoticed, leaving healthcare providers with unresolved pending claims. Moreover, when claims are rejected or denied, the process of identifying the reasons for rejection or non-payment typically involves manual checking. This manual process is time-consuming and prone to errors, leading to delays in resolving issues and potentially resulting in lost revenue for healthcare providers. Additionally, leftover claims that are neither submitted nor addressed after an initial submission failure are often left as they are, without further action. This inaction can lead to significant financial losses and inefficiencies in the billing process. For healthcare providers, accurate billing details are crucial not only for receiving proper compensation for services rendered but also for maintaining smooth cash flow. For insurance companies, this data aids in verifying coverage, detecting potential fraud, and ensuring prompt reimbursement. Accurate financial information helps prevent billing errors and claim denials, which are common issues in the healthcare billing ecosystem. SUMMARY A bulk insurance claims re-submission system and process is disclosed herein which deals with the re-submission of pending insurance claims, that may have been denied or otherwise rejected, to the payer by uploading all the pending insurance claims in bulk. In an embodiment of the present disclosure, an automatic bulk insurance claims re-submission method is disclosed. The automatic bulk insurance claims re-submission method for the pending insurance claims is disclosed. The automatic bulk insurance claims re-submission method involves extracting past insurance claims that remain pending due to non-submission, denial or rejection by one or more payers for various reasons, classifying these as pending insurance claims. Further, the Electronic Remittance Advice (ERA) reconciliation data provided by the payer is analyzed to identify discrepancies between expected and actual payments. The payment status and reasons behind non-payment for each pending claim are determined. A set of necessary modifications are then implemented to ensure that the claims meet approval criteria. Finally, the automatic bulk insurance claims re-submission method automatically resubmits the modified pending claims in a single bulk upload, ensuring that all corrected claims are accurately reflected in the submission, and ensuring that the efficiency and accuracy of the insurance claim re-submission process are maintained, leading to improved reimbursement outcomes for healthcare providers. In addition, an automatic bulk insurance claims re-submission system is disclosed. The automatic bulk insurance claims re-submission system for automatic bulk re-submission of pending insurance claims includes a computer system with one or more processors and databases, operatively coupled to the processors, to perform specific operations. “Pending” claims includes non-submitted claims and submitted but rejected claims. The automatic bulk insurance claims re-submission system extracts past insurance claims that are pending, either due to non-submission, denial or rejection by one or more payers for various reasons, classifying these as pe