System and method for processing medical claims
Inventors
GUANERI, Joseph • Posnack, Daniel • Arn, Peter • Para, Wendy • Hacking, S. Adam • Mueller, Micheal • Greene, Jonathan • Mason, Steven
Assignees
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Publication Number
US-12327623-B2
Publication Date
2025-06-10
Expiration Date
Abstract
A computer-implemented system for processing medical claims is disclosed. The system includes a medical device configured to be manipulated by a user while the user performs a treatment plan; a patient interface associated with the medical device, the patient interface comprising an output configured to present telemedicine information associated with a telemedicine session; and a processor. During the telemedicine session, the processor is configured to receive information from a medical device. Using the device-generated information, the processor is further configured to determine device-based medical coding information. The processor is further configured to transmit the device-based medical coding information to a claim adjudication server.
Core Innovation
The disclosed invention provides a telemedicine-enabled medical claim processing architecture in which an electromechanical device is configured to be manipulated by a user while the user performs a treatment plan. The electromechanical device generates device-generated information during the telemedicine session, and a processor determines device-based medical coding information based on the device-generated information.
The processor transmits the device-based medical coding information to a claim adjudication server. In the clinic workflow, reviewed medical coding information is received, and the system computes a match or reconciliation indicator based on the reviewed coding and the device-based coding information.
The disclosure further introduces a cloud-based learning system in which machine learning models are trained using historical device-generated information, historical device-based coding information, historical reviewed coding information, and historical determinations on whether the historical reviewed coding information can be reconciled with the historical device-based coding information, including computer-based and human-based determinations.
Claims Coverage
The independent claims define a computer-implemented system and clinic-server method that use electromechanical-device-generated device-generated information during a telemedicine session to determine device-based coding information using one or more machine learning models, and then transmit that coding information to a claim adjudication server. Across the independent claims, the inventive features include user-manipulated electromechanical devices during treatment plans, patient interfaces presenting telemedicine information, machine-learning model generation and training using historical reviewed and reconciliability determinations, and downstream transmission to a claim adjudication server, with additional emphasis on exercises performed.
User-manipulated electromechanical device during a treatment plan
An electromechanical device configured to be manipulated by a user while the user performs a treatment plan; the device generates device-generated information during the telemedicine session.
Patient interface presenting telemedicine information
A patient interface associated with the electromechanical device and configured to present telemedicine information associated with a telemedicine session.
Machine learning models determine healthcare services or exercises
Generate one or more machine learning models trained to determine healthcare services provided during the telemedicine session based on device-generated information generated by the electromechanical device while the user performs the treatment plan; alternatively, determine exercises that are performed during the telemedicine session based on the device-generated information.
Device-based coding determination and transmission to claim adjudication server
Determine, by using the one or more machine learning models and based on the device-generated information, device-based coding information; transmit the device-based coding information to a claim adjudication server.
Training using historical reconciliability determinations
Generate the one or more machine learning models using training data comprising historical device-generated information; historical device-based coding information; historical reviewed coding information; historical computer-based determinations on whether the historical reviewed coding information can be reconciled with the historical device-based coding information; and historical human-based determinations on whether the historical reviewed coding information has been reconciled with the historical device-based coding information.
Clinic server method receiving device data and processing telemedicine session
Receive device-generated information from an electromechanical device while a user performs a treatment plan; present, with a patient interface associated with the electromechanical device, telemedicine information associated with a telemedicine session; generate one or more machine learning models trained to determine exercises that are performed during the telemedicine session based on the device-generated information; determine device-based coding information using the models and the device-generated information; and transmit the device-based coding information to a claim adjudication server.
Across the independent claims, claim coverage centers on telemedicine sessions supported by an electromechanical device manipulated during a user-performed treatment plan, using machine learning models to determine services or exercises from device-generated information, deriving device-based coding information and transmitting it to a claim adjudication server, and training the models using historical reviewed coding information together with computer-based and human-based reconciliability determinations.
Stated Advantages
Reduced network load by bypassing multiple databases/servers and transmitting coding directly.
Documented Applications
Telemedicine-enabled medical claim processing using an electromechanical device that generates device data during a treatment plan, producing device-based medical coding information for submission to a claim adjudication server.
Training machine learning models in a cloud-based training system using historical device data, device-based codes, reviewed codes, and reconciled or reconcilable coding determinations.
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