US 12,148,534 B1
System and method for automated enforcement of policies
William Lamar Kerr, Tampa, FL (US); Jason Eric Bush, Citrus Park, FL (US); and Michael Adrian Shaffer, Lutz, FL (US)
Assigned to Avalon Heath Services, LLC, Tampa, FL (US)
Filed by Avalon Health Services, LLC, Tampa, FL (US)
Filed on Sep. 25, 2018, as Appl. No. 16/141,459.
Claims priority of provisional application 62/562,525, filed on Sep. 25, 2017.
Int. Cl. G06Q 40/10 (2023.01); G06N 5/025 (2023.01); G16H 70/20 (2018.01)
CPC G16H 70/20 (2018.01) [G06N 5/025 (2013.01)] 20 Claims
OG exemplary drawing
 
1. A computer-implemented method for editing one or more claims comprising:
receiving, via a processor, one or more real-time web service calls, each call comprising a claim, wherein each claim is relative to a health care plan, wherein each healthcare plan utilizes a unique web-path configured to facilitate variations in processing each claim, wherein the unique web-path includes a white-listed internet protocol (IP) address using hypertext transfer protocol secure (HTTPS) and a uniform resource locator (URL);
communicating, via a network, with one or more servers belonging to at least one of the health plan provider or a vendor to verify a member ID associated with each claim, wherein a load balancer directs the one or more real-time web service calls for each claim along a corresponding unique web-path;
applying a plurality of rules to each claim in response to receiving each claim and after verifying the member ID associated with each claim, wherein the plurality of rules include health care policy rules of the health care plan that includes a specific medical policy, wherein applying the plurality of rules to each claim includes
sending each claim to the vendor,
receiving claim history from the vendor,
applying the health care policy rules to each claim based on at least the claim history and the received one or more previous claims, wherein the claim history includes one or more previous claims and the medical procedure associated with each previous claim;
generating a recommendation, within a sub-second response time, in response to applying the plurality of rules to each claim, wherein the recommendation is a result of applying the plurality of rules to each claim, wherein the recommendation includes at least one of an appropriate amount for the health plan provider to pay or whether each claim should be denied or reduced;
sending the recommendation as a web service response; and
storing the recommendation on a memory system in response to generating the recommendation, wherein the memory system includes one or more servers configured to dynamically expand or reduce storage capacity during periods of peak volume.