IT201600119575A1 - Method and system for organizing and managing data relating to the performance of workers with reference to medical and health assistance - Google Patents

Description

"Method and system for the organization and management of data relating to the performance of workers with reference to medical and health care"

DESCRIPTION

The present invention refers to a method and system for managing the flow of data in the field of medical and health care, in particular to such a method and system for the management of practices related to requests for reimbursement for medical and health care expenses.

State of the art.

In today's world, the system that manages the presentation, acceptance, and management of practices related to requests for reimbursement for medical and health expenses by working citizens, as well as the disbursement of such reimbursements by the institution once the request has been accepted and the fulfillment of the requisites for obtaining such reimbursement has been verified, it is very complex and takes a very long time to complete the bureaucratic process.

In fact, with the procedure currently in use relating to reimbursement to citizen workers for medical or similar expenses, a worker who needs a professional or outpatient medical examination, or hospitalization for surgery and subsequent hospital course, for which payment is required by part of the worker to the professional or to the institution responsible for hospitalization, is forced to advance the money in order to receive the required medical assistance.

Furthermore, this procedure currently in use obliges the worker, who intends to receive reimbursement of such medical expenses already incurred, to present a plurality of documents to be presented to the responsible body, some of which are sometimes not easily available and / or traceable and / or not easy to compile. This body in charge, in a first phase, or at the moment of the submission of the application by the applicant worker, only verifies that all the formal aspects of the request have been satisfied. Only subsequently, this body in charge verifies the existence or otherwise of the rights to obtain the requested reimbursement, the amount payable, and at the end will start the banking procedure to pay the applicant the amount due. This whole procedure requires long waiting times, verification, activation of controls by even more offices in charge; the result of this complex procedure is that the worker, after having incurred the expenses out of his own pocket, is forced, in the best case, to wait even a few months to be reimbursed for these expenses, or, in the worst case, to receive a negative response to your request for reimbursement of expenses.

Therefore, in this context, the Applicant of this patent application found the need to improve this procedure, shortening the time and streamlining the refund request procedure itself.

Summary of the invention.

In a first aspect, this problem has been solved according to the present invention by a method such as that indicated in claim 1.

The present invention in fact refers to a system and relative method for managing requests for reimbursement for medical-health services, establishing control procedures between the data presented by an applicant and the data present in predetermined and updatable lists from time to time.

The Applicant of the present application has in fact surprisingly found that a method for managing a system relating to requests for reimbursement for medical-health services, a method which includes the steps of:

a) create and keep updated a first list of persons entitled to such reimbursements, a second list of said medical and health services for which reimbursement is envisaged to those entitled and a third list of recognized bodies from which it is possible to carry out the medical-health service requested in order to have said reimbursement requested;

b) enter a new request for reimbursement in the system, including an identification code of the applicant, the medical and health service requested, the institution where said medical and health service is carried out and the amount of the reimbursement requested;

c) verify that said applicant of said new refund request is present in said first list of persons entitled to said refunds;

d) in the affirmative, verify that the reimbursement requested relates to a medical-health service present in said second list of said medical-health services and, if so, that said institution in which said medical-health service is carried out is present in the third list of recognized entities;

e) if so, activate the procedure for the disbursement of the requested reimbursement, it is able to streamline the procedure for the reimbursement of expenses incurred for medical and health services.

In fact, the method of the present invention allows an applicant, or an agent of his, to enter his request for reimbursement directly into the system, without having to personally go to an office responsible for assistance in this management of the case.

Furthermore, the method of the present invention allows an immediate verification by the system that manages the requests for reimbursements to verify whether the name of the applicant for a new reimbursement is already included in a list of persons entitled to such reimbursements.

Finally, the method of the present invention allows an immediate verification also relating to the fact whether the medical-health service and the institution where such service is performed belong or not, respectively, to a list of medical-health services for which it is actually reimbursement is foreseen, and to a list of affiliated entities for the execution of this service.

Once all the necessary verifications described above have been made, the method of the present invention allows the activation of the refund procedure to the person who requested it.

These phases make it possible to drastically reduce waiting times for obtaining a refund, at the same time giving a complete and precise picture of the refunds paid to each individual applicant, avoiding possible errors that could occur with the procedures currently in force.

In the present description and in the attached claims, the term "medical-health services" means all those services, such as outpatient medical examinations, specialist medical examinations, surgical interventions, care and extraction of teeth, installation of supporting devices for the teeth, hospital admissions, transport costs for people with disabilities, and other similar services in the medical-health field.

In this description and in the attached claims, the term "applicant" means a person duly registered as an employee of a company, and who as such has the right to medical and health care in accordance with the regulations in force. This term also means any family element borne by the "applicant" as described above.

In this description and in the attached claims, the term "applicant's identification code" means a code, such as the tax code or other alphanumeric code that uniquely identifies, without the possibility of error, a particular applicant, avoiding problems due to any homonymy between two applicants.

In this description and in the attached claims, the term "recognized bodies" means all hospitals, private medical facilities, laboratories, specialized centers, previously recognized as suitable for the performance of certain medical and health services.

According to a preferred embodiment, said method uses at least one computerized management unit which can also be accessed remotely via cable connection, internet, wi-fi or the like.

In this way, this computerized management unit allows to act as a centralized unit to which the various applicants can be connected from corresponding peripheral stations connected to it.

According to a preferred embodiment, said step of entering a new refund request into the system is carried out directly by the person concerned or by his representative by connecting to said computerized management unit, even remotely.

In this way, each individual applicant can access the computerized management unit directly from their office, from home, from their laptop or even from their mobile phone.

According to a preferred embodiment, an identification code is associated in a univocal way to each name of a person present in said first list.

In this way it is not possible to have homonymy problems; each individual user has his own identification code.

According to a preferred embodiment, each applicant can access the system after having received his own personal access password.

In this way, the security requirements for computer access to the system are met.

According to a preferred embodiment, said verification step indicated in point c) is carried out through a comparison between the identification code associated with a name present in said first list of entitled to reimbursement and the identification code associated with the applicant of said new request refund.

This ensures that the new refund request is made by a person entitled to the refund. If the applicant's name is not present in the list of persons entitled to reimbursement, the system warns the applicant that his request was not successful. It will therefore be the responsibility of this applicant to take steps to ensure that his name is included in this list, provided he has the rights. Otherwise, a refund attempt to a person not entitled to such a refund will have been avoided.

According to a preferred embodiment, the applicant, at the time of entering the data relating to a new refund request, will also enter the data relating to the company where he works.

In this way it is possible to have statistical data on the amount of reimbursements requested by the employees of each single company that has at least one employee included in this list of reimbursement applicants.

According to a preferred embodiment, if the medical-health service for which a reimbursement is requested is not present in said second list of said medical-health services, the system warns the applicant that his request has not been successful. It will therefore be the responsibility of this applicant to take steps to ensure that this medical-health service is included in this list of eligible services to receive reimbursement, provided that he / she has the appropriate requirements. Otherwise, a refund attempt will have been avoided for a service for which no type of refund is envisaged.

According to a preferred embodiment, if the institution in which said medical-health service is performed is not present in said third list of recognized institutions where it is possible to perform this medical-health service for which reimbursement is requested, the system warns the applicant that his request was unsuccessful. It will therefore be the responsibility of this applicant to take steps to ensure that this body is included in this list of bodies suitable for carrying out this medical and health service in order to receive a refund, provided that it has the appropriate requirements. Otherwise, a refund attempt will have been avoided for a service performed at an institution that is not recognized as eligible to perform a reimbursement-worthy medical service.

According to a preferred embodiment, the method of the present invention further comprises creating and keeping up-to-date a fourth list of refunds granted for a given applicant.

In this way it is possible to have a historical trend of the type and amount of reimbursements requested by each individual applicant.

According to a preferred embodiment, the system can establish an overall maximum reimbursement limit for each individual applicant.

According to a preferred embodiment, the system can establish a maximum reimbursement ceiling for each type of medical-health service for each applicant.

In this way, the reimbursement body can set a limit on the reimbursements to be disbursed, avoiding reimbursement of any type of request.

According to a preferred embodiment, the method of the present invention comprises a further step of verifying between the amount of the reimbursement requested and the sum of the amounts relating to reimbursements already paid to that same applicant, both as a whole and referred to that particular medical service. - healthcare for which the current refund request was made.

In this way, the phase of disbursement of the requested reimbursement is activated only after the verification that the applicant of said reimbursement request has not already benefited from a reimbursement for one or more previous reimbursements for a total amount equal to or greater than a pre-established maximum limit. .

In a second aspect, this problem has been solved according to the present invention by a system such as that indicated in claim 8.

The Applicant of the present application has in fact surprisingly found that a system for the management of requests for reimbursement for medical-health services, a system which includes:

i) at least one computerized management unit, which can also be accessed remotely via cable, internet, wi-fi or similar connection.

ii) a first updateable list of persons entitled to such reimbursements and identifiable through a unique identification code; a second list of said medical-health services for which reimbursement is envisaged to those entitled; and a third list of recognized bodies from which it is possible to perform the medical-health service requested in order to have said reimbursement requested, said first, second and third list being loaded on said computerized management unit or on devices connected to it by connection via cable, internet, wi-fi or similar and being updatable and able to provide data extracted from them upon request;

iii) a first form for the insertion in said computerized management unit, or in said devices connected to it, of data relating to a new refund request by an applicant, where said data includes at least one identification code associated with said applicant, the medical-health service requested, the institution where said medical-health service is performed, and the amount of the reimbursement requested for said medical-health service;

iv) a first control procedure which verifies whether the name of the applicant for the new refund request is present in the said first list of persons entitled to such refunds;

v) a second control procedure which verifies whether said medical-health service is present in said second list of said medical-health services; vi) a third control procedure that verifies whether the body where said medical and health service is carried out is present in said third list of recognized bodies;

vii) a second module to activate the disbursement of said reimbursement requested, is able to streamline the procedure for reimbursement of expenses incurred for medical and health services.

In particular, all the advantages indicated above, with reference to the method according to a first aspect of the present invention, are valid in equal measure to the system described here according to a second aspect of the present invention.

Similarly, all the lists of applicants, medical and health services and bodies suitable to perform such services, as well as all the verification procedures between a new request for reimbursement and the data present in the system, seen with reference to the first aspect of the invention, are also found in this second aspect of the present invention.

According to a preferred embodiment, said system also includes, for each person entitled to said reimbursements, the total amount of reimbursements already paid in a given period of time.

According to a preferred embodiment, said system also includes, for each person entitled to said reimbursements, the total amount of reimbursements already paid in a given period of time for each type of medical-health service.

The present invention is illustrated hereinafter in greater detail with reference to an exemplary and non-limiting embodiment thereof.

Detailed description

Some examples of the method and system of the present invention are shown below.

Example 1.

A list of workers in companies is available on a unit present on a computerized platform, each of whom has the right to reimbursement for expenses incurred for medical and health services for himself or for any of his dependents.

Table 1 below shows an example of this list of names, in alphabetical order:

Table 1

Surname Name Company Code

Bianchi Carlo BNCCRL60N18F345B Alfa

Neri Antonio NRINTN55F14B567D Beta

Rossi Massimo RSSMSS50R25E123A Range

Verdi Giovanni VRDGVN70P11G345C Alfa

Table 2 below shows the list of medical and health services and the recognized bodies where such medical and health services are performed for which a reimbursement of expenses incurred by a worker belonging to the list indicated in Table 1 is recognized:

Table 2

Type of service Recognized body 1 Recognized body 2 Recognized body 3 Dental examination Study S1 Hospital O1 Clinic C1 Pediatric examination Study S1 Study S2 Study S3 Orthopedic examination Study S1 Hospital O1 Hospital O2 Eye examination Study S1 Study S4 Study S5 The table 3 below shows the updated situation which shows, for each of the workers belonging to the list indicated in Table 1, the amount of reimbursements paid and the residual amount still payable for each individual medical and health service in the current year, by virtue of a maximum limit reimbursable pre-established by the body that disburses the reimbursements within a year, defined as: Euro 1,500 for dental visits, Euro 2,500 for pediatric visits, Euro 4,000 for orthopedic examinations, Euro 3,000 for eye examinations.

Table 3

Surname Name Type of benefit Reimbursements paid Residual reimbursement payable Bianchi Carlo Dental examination Euro 1,000 Euro 500 Bianchi Carlo Pediatric examination Euro 1,500 Euro 1,000 Bianchi Carlo Orthopedic examination Euro 2,000 Euro 2,000 Bianchi Carlo Eye examination Euro 2,000 Euro 1,000 Neri Antonio Dental examination Euro 500 Euro 1,000 Blacks Antonio Pediatric examination Euro 1,000 Euro 1,500 Neri Antonio Orthopedic examination Euro 1,000 Euro 3,000 Neri Antonio Eye examination Euro 3,000 No refund Rossi Massimo Dental examination Euro 1,500 No refund Rossi Massimo Pediatric examination Euro 2,500 No refund Rossi Massimo Orthopedic examination Euro 1,000 Euro 3,000 Rossi Massimo Visit ophthalmology Euro 1,500 Euro 1,500 Verdi Giovanni Dental examination Euro 0 Euro 1,500 Verdi Giovanni Pediatric examination Euro 2,000 Euro 500 Verdi Giovanni Orthopedic examination Euro 3,500 Euro 500 Verdi Giovanni Eye examination Euro 3,000 No reimbursement In the example 1 shown here, the applicant Verdi Giova nni, with identification code VRDGVN70P11G345C and employed by Alfa company, directly from one of his personal computers connects to the platform used to receive requests for reimbursement for expenses incurred for medical and health services. At the time of access, the applicant enters his access password in the appropriate form used for such requests, after which he enters the data relating to his request, namely:

surname: Verdi

name: Giovanni

code: VRDGVN70P11G345C

company: Alfa

service: orthopedic visit

institution: hospital O1

reimbursement: Euro 400

The system after verifying, in order, that:

- the applicant (Verdi Giovanni with code VRDGVN70P11G345C) is present in the list shown in Table 1,

- the medical-health service (orthopedic visit) is one of those recognized as worthy of reimbursement as per Table 2,

- the body (hospital O1) where this medical and health service is performed (orthopedic visit) is a recognized body as per Table 2,

- the applicant, having received a reimbursement of Euro 3,500 in the current year, has not yet reached the maximum limit (Euro 4,000) envisaged for this medical-health service (orthopedic visit) and therefore still has a refund payable for that service equal to to Euro 500, as indicated in Table 3,

- the reimbursement requested is Euro 400, and therefore lower than the reimbursement still payable for the medical and health service requested,

activates the procedure for reimbursement to the applicant, by check, bank transfer or other previously established forms of payment, informs the applicant that the request has been accepted and updates their lists.

Example 2

In this case, an applicant entered the following data:

surname: Gialli

name: Massimo

code: GLLMSS57R31H789A

company: Alfa

service: orthopedic visit

institution: hospital O1

reimbursement: Euro 1,000

The system, after verifying that this name is not present in the list of those entitled to refunds shown in Table 1, informs the applicant that the refund request has not been accepted.

If the applicant believes that he is nevertheless entitled to such reimbursement, he will ensure that his name is added to this list by contacting the body responsible for maintaining and updating this list.

Example 3

In this case, an applicant entered the following data:

surname: Verdi

name: Giovanni

code: VRDGVN45P13G456B

company: Alfa

service: orthopedic visit

institution: hospital O1

reimbursement: Euro 400

The system, after verifying that, although this name is present in the list of those entitled to reimbursements shown in Table 1, but that the applicant's identification code does not correspond to that present in this list, it informs the applicant that the reimbursement request was not accepted.

If the applicant believes that he is still entitled to such a refund, he will ensure that his name and the corresponding identification code is added to this list, by contacting the body responsible for maintaining and updating this list.

Example 4.

In this case, an applicant entered the following data:

surname: Verdi

name: Giovanni

code: VRDGVN70P11G345C

company: Alfa

performance: needle-puncture treatment

institution: study S1

reimbursement: Euro 500

The system, after verifying that, even if this applicant is entitled to reimbursements, as both the name and the relative code are present in the list of those entitled to reimbursements shown in Table 1, however the requested service does not belong to those deserving of refunds (does not belong to the list shown in Table 2), informs the applicant that the refund request has not been accepted.

If the applicant believes he is still entitled to this reimbursement, he will ensure that this medical and health service is included in those for which a reimbursement is envisaged, by contacting the body responsible for maintaining and updating this list.

Example 5.

In this case, an applicant entered the following data:

surname: Verdi

name: Giovanni

code: VRDGVN70P11G345C

company: Alfa

service: orthopedic visit

institution: study S2

reimbursement: Euro 500

The system, after verifying that, even if this applicant is entitled to reimbursement, as both the name and the relative code are present in the list of those entitled to reimbursement shown in Table 1, even if the requested service (orthopedic visit) belongs to those deserving of reimbursement as it is present in the list shown in Table 2, however, the S2 office where this eye examination is performed is not an institution deemed suitable to carry out this orthopedic examination in order to obtain reimbursement for that service , informs the applicant that the refund request has not been accepted.

If this applicant believes that he is nevertheless entitled to such reimbursement, he will ensure that the institution where such medical and health service is carried out is included in the list of institutions recognized as eligible to carry out this visit in order to obtain reimbursement for that performance, by contacting the body responsible for maintaining and updating this list.

Example 6.

In this case, an applicant entered the following data:

surname: Verdi

name: Giovanni

code: VRDGVN70P11G345C

company: Alfa

service: eye examination

institution: study S1

reimbursement: Euro 500

The system, after verifying that, even if this applicant is entitled to reimbursement, as both the name and the relative code are present in the list of those entitled to reimbursement shown in Table 1, even if the requested service (eye examination) belongs to those deserving of reimbursement as it is present in the list shown in Table 2, even if the S1 study where this eye examination is performed is an institution deemed suitable to carry out this examination in order to obtain reimbursement for that service, such as shown in Table 2, however, this applicant has already received a reimbursement of Euro 3,500 in the current year and has therefore reached the maximum limit (Euro 3,500) envisaged for this medical-health service (eye examination) and is therefore not entitled to any further reimbursement payable for that type of medical-health service, as indicated in Table 3, informs the applicant that the reimbursement request was not received accepted.

The system and method of the present invention also make it possible to extrapolate from the updated lists statistical information relating, for example, to the reimbursements disbursed for the employees of a certain company, the reimbursements disbursed for a specific medical-health service, the entities most used to carry out a certain medical-health service, etc.

Such statistical information can be used, for example, in order to verify whether the maximum amounts established for each individual medical and health service for each person entitled over a year are suitable or subject to change, or which are the companies whose employees make more use of this reimbursement procedure for health care benefits.

The system and method of the present invention, in addition to speeding up the times for providing refunds, also allows to avoid human errors in accepting requests for refunds and activating the related refund even when the rights do not exist. The present invention has been described herein with reference to its preferred embodiments, but it will be understood that equivalent modifications may be made without departing from the scope of the protection accorded thereto.

However, other embodiments of the method and system of the present invention are also possible.

Consequently, the scope of protection of the present invention must not be limited to the particular embodiments described above only by way of example, but must be considered according to the attached claims.

Claims (10)

CLAIMS 1. Method for managing a system relating to requests for reimbursement for medical and health services, a method which includes the steps of: a) create and keep up-to-date a first list of persons entitled to such reimbursements, a second list of said medical and health services for which reimbursement is envisaged to the entitled persons and a third list of recognized bodies from which it is possible to carry out the medical health service requested in order to have said reimbursement requested; b) enter a new request for reimbursement in the system, including an identification code of the applicant, the medical and health service requested, the institution where said medical and health service is carried out and the amount of the reimbursement requested; c) verify that the applicant of said new refund request is present in said first list of persons entitled to said refunds; d) in the affirmative, verify that the reimbursement requested relates to a medical-health service present in said second list of said medical-health services and, if so, that said institution where said medical service is performed is present in said third list of recognized entities; e) if so, activate the procedure for the disbursement of the requested reimbursement. 2. Method according to claim 1, wherein said method uses at least one computerized management unit which can also be accessed remotely via cable connection, internet, wi-fi or the like. 3. Method according to any of the previous claims in which, said step of entering a new refund request into the system is carried out directly by the person concerned or by his representative by connecting to said computerized management unit, even remotely. 4. Method according to any one of the preceding claims in which an identification code is associated in a univocal way to each name of a person present in said first list. 5. Method according to any one of the preceding claims in which, said verification step indicated in point c) is carried out by means of a comparison between the identification code associated with a name present in said first list of entitled to reimbursement and the identification code associated with the applicant for said new reimbursement request. Method according to any one of the preceding claims which further comprises creating and maintaining updated a fourth list of refunds granted for a particular applicant. 7. Method according to claim 6 wherein said disbursement of the requested reimbursement is activated after verifying that the applicant for said reimbursement has not already benefited from one or more previous reimbursements for a total amount equal to or greater than a predetermined maximum limit. 8. System for the management of requests for reimbursement for medical and health services, a system which includes: i) at least one computerized management unit, which can also be accessed remotely via cable, internet, wi-fi or similar connection; ii) a first updateable list of persons entitled to such reimbursements and identifiable by means of a unique identification code; a second list of said medical-health services for which reimbursement is envisaged to those entitled; and a third list of recognized bodies from which it is possible to perform the medical-health service requested in order to have said reimbursement requested, said first, second and third list being loaded on said computerized management unit or on devices connected to it by connection via cable, internet, wi-fi or similar and being updatable and able to provide data extracted from them upon request; iii) a first form for the insertion in said computerized management unit, or in said devices connected to it, of data relating to a new refund request by an applicant, where said data includes at least one identification code associated with said applicant, the medical-health service requested, the institution where said medical-health service is performed, and the amount of the reimbursement requested for said medical-health service; iv) a first control procedure which verifies whether the name of the applicant for the new refund request is present in the said first list of persons entitled to such refunds; v) a second control procedure which verifies whether said medical health service is present in said second list of said medical health services; vi) a third control procedure that verifies whether the body in which said medical and health service is carried out is present in said third list of recognized bodies; vii) a second form to activate the disbursement of the requested reimbursement. 9. System according to claim 8 which also includes, for each person entitled to said reimbursements, the total amount of reimbursements already paid in a given period of time. 10. System according to claim 8 which also includes, for each person entitled to said reimbursements, the total amount of reimbursements already paid in a given period of time for each type of medical and health service.