Mckesson Corporation

Mckesson Financial Holdings

Patrick I Harris, Sr

Roger George Pinsonneault

Jessica Russell

Patricia A daCosta

Tracy Highton

An adjudicated prescription claim transaction response is received and includes a total amount paid by the claims processor, a patient pay amount, and the pharmacy's Usual and Customary Charge amount for a product/service. The adjudicated response can be evaluated to determine it was approved/paid and the total amount paid by the claims processor is zero or less. An income audit evaluation may be conducted by comparing the patient pay amount to the Usual and Customary Charge amount. Based on the Usual and Customary Charge amount being less than or less than or equal to the patient pay amount, a reversal transaction can be generated and transmitted to a claims processor computer for adjudication. Further, the adjudicated prescription claim transaction response can be converted from an approved/paid response to (or replaced by) a rejected adjudicated prescription claim transaction response and transmitted to the pharmacy computer that initiated the prescription claim transaction.

Systems and methods for auditing discount card-based healthcare purchases

The evaluation system provides a real-time mechanism for auditing purchase request transactions prior to the purchase being completed in order to determine if one or more audit parameters are violated and the transaction should not be completed. An electronic product request can be received from a merchant of the product. The request can identify at least the merchant, the party, and the product requested for purchase. One or more business rules and auditing parameters for auditing the request can be identified based on the identity of the merchant. The contents of the request can then be audited to determine if the request satisfies the audit parameters. The contents of the request can also be used to identify historical transactions for the party, which can be used to determine if the current request violates one or more of the audit parameters.

System and method for evaluating requests

An adjudicated response to a healthcare transaction for a product or service for a patient is received and includes a transaction submission time, and transaction comparison data. The transaction comparison data can be compared to a multitude of transaction records of previously processed healthcare transactions to identify a match. The transaction submission time for each of the received healthcare transaction and stored healthcare transaction can be received and compared to one another to determine a submission time difference between the submission time for the healthcare transaction and the stored healthcare transaction. The submission time difference can be compared to a time limit threshold to determine if the difference satisfies the time limit threshold. Based on the determination that the submission time difference satisfies the threshold, the received healthcare transaction can be determined to be a request for a service, such as prior authorization assistance.

Systems and methods for identifying prior authorization assistance requests in healthcare transactions

Systems and methods are provided for determining the operational status of third-party switch/service providers. The service provider computer receives healthcare transactions and determines if each transaction is to be processed by a third-party switch provider system, either under a contract between the pharmacy and the third-party switch provider or under an exclusivity arrangement between the transaction payer and the third-party switch provider. Healthcare transactions are sent to the third-party switch provider for processing. If the transmission is not successful, the service provider computer will determine if the third-party switch provider system is operating. If determined to not be operating, the service provider computer will process on its own the healthcare transactions that are typically processed by the third-party switch provider system due to contractual agreement with the pharmacy that sent the transaction for as long as the third-party switch provider system is determined to be not operating.

Systems and methods for determining operational status of third-party service providers

Systems and methods for identifying healthcare transactions with a risk of failing to include appropriate directions for use are provided. A healthcare claim transaction may be received from a healthcare provider computer. Based upon an analysis of the received healthcare claim transaction, identification information for a prescriber may be determined. A determination may be made as to whether the identified prescriber is an at-risk prescriber that has previously failed to include appropriate directions for use in association with a prescription. If it is determined that the prescriber is an at-risk prescriber, then a predetermined control action may be implemented. Otherwise, if it is determined that the prescriber is not an at-risk prescriber, then the healthcare claim transaction may be communicated to a claims processor computer associated with a claims processor.

Systems and methods for identifying healthcare transactions with a risk of failing to include appropriate directions for use

Systems and methods are provided for generating edits for healthcare transactions to address billing discrepancies. Information associated with an audit performed on a healthcare transaction may be received. Based at least in part on the received information, a billing discrepancy associated with the healthcare transaction may be identified. Based upon the identified billing discrepancy, a proposed edit may be generated that can be utilized to mitigate an impact of the identified billing discrepancy during the processing of one or more subsequent healthcare transactions.

Systems and methods for generating edits for healthcare transactions to address billing discrepancies

Embodiments of the invention may include systems and methods for notifying a prescriber or other entity of duplicate product prescriptions. According to one embodiment, a method for processing prescriptions is provided that may include the operations of: receiving a healthcare transaction that identifies a current prescribed product, a patient, and a current prescriber who prescribed the current prescribed product; retrieving patient history for the patient; determining the following based on the patient history: that the patient has previously received a previous equivalent product equivalent to the current prescribed product identified in the healthcare transaction and an identity of a previous prescriber of the previous equivalent product; and transmitting a notification to at least one of the previous prescriber or the current prescriber, wherein the notification identifies potential duplicate products.

Systems and methods for notifying of duplicate product prescriptions

Systems and methods are provided for supporting and validating patient enrollment in one or more healthcare programs. The systems and methods may include receiving a prescription claim request from a pharmacy computer, where the prescription claim request includes at least (i) a first product identifier identifying with a prescribed product for a patient, and (ii) patient information associated with the patient; determining, based at least in part upon the first identifier, that patient is subject to a requirement to enroll in one or more required healthcare programs prior to the prescription product being released to the patient; extracting enrollment information from the prescription claim request, the extracted enrollment information including at least a portion of the patient information from the prescription claim request; and automatically utilizing the extracted enrollment information to complete at least a portion of an enrollment process for the one or more required healthcare programs.

Systems and methods for streamlined patient enrollment for one or more healthcare programs

Systems and methods are provided for the coordination of benefits. The systems and methods may include receiving a healthcare claim request from a healthcare provider computer; determining, based at least in part from patient information in the healthcare transaction claim request, that the patient is associated with at least a first payer and a second payer; generating a primary claim request based upon the identified product and the patient associated with the healthcare claim request, the primary claim associated with the first payer; and generating a coordination of benefits (COB) claim request based at least in part on the received first adjudicated reply associated with the primary claim request, the COB claim request, the COB claim request associated with a second payer.

Growing community of inventors

Atlanta, GA, United States of America

Patrick I Harris, Sr