System and method for detecting fraudulent medical claims via examination of service codes

Claim 2

In a computer system having means for operating on a predetermined database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when input with other selected ones of the medical service codes, a method for processing input claims containing at least one medical service code, comprising the steps of: receiving at least one claim; ascertaining whether the at least one claim contains a plurality of medical service codes; determining whether one of the medical service codes in the at least one claim is mutually exclusive due to non-medical criteria with any other medical service code in the at least one claim; authorizing medical service codes which are not mutually exclusive due to non-medical criteria with any other medical service codes contained in the at least one claim in response to the determining step; and rejecting medical service codes which are mutually exclusive due to non-medical criteria with any other medical service codes contained in the at least one claim in response to the determining step.

Claim 3

A computer system including a central processing unit and associated memory for processing input claims containing at least one medical service code, comprising: a predetermined database stored in the associated memory, the database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when received with other selected ones of the medical service codes; means for receiving at least one claim; means for ascertaining whether the at least one claim contains a plurality of medical service codes; means for determining whether one of the medical service codes in the plurality of medical service codes is valid or invalid by interacting with the database and the set of relationships contained in the database; means for authorizing medical service codes which are valid in response to the means for determining; and means for rejecting medical service codes which are invalid in response to the means for determining.

Claim 4

The apparatus of claim 3, further comprising means for revising the at least one claim to delete invalid medical service codes.

Claim 5

The apparatus of claim 4, further comprising means for informing a user why the at least one claim was revised.

Claim 6

The apparatus of claim 3, wherein the database containing medical service codes includes medical service codes described by CPT codes.

Claim 7

The apparatus of claim 3, wherein the database containing medical service codes includes medical service codes described by CRVS codes.

Claim 8

The apparatus of claim 3, further comprising means for requesting further information from a user regarding the at least one claim.

Claim 9

The apparatus of claim 3, wherein the relationships among the medical service codes include medically determined relationships.

Claim 10

A computer system including a central processing unit and associated memory for processing input claims containing at least one medical service claim, comprising: a predetermined database stored in the associated memory, the database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when received with other selected ones of the medical service codes; means for receiving at least one claim; means for ascertaining whether the at least one claim contains a plurality of medical service codes; means for determining whether one of the medical service codes in the at least one claim is included in any other medical service code in the at least one claim; means for authorizing medical service codes which are not contained in any other medical service code; and means for rejecting medical service codes which are contained in any other medical service code.

Claim 11

The apparatus of claim 10, further comprising means for revising the at least one claim to not include a rejected medical service code.

Claim 12

A computer system including a central processing unit and associated memory for processing input claims containing at least one medical service code, comprising: a predetermined database stored in the associated memory, the database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when received with other selected ones of the medical service codes; means for receiving at least one claim; means for ascertaining whether the at least one claim contains a plurality of medical service codes; means for determining whether one of the medical service codes in the at least one claim is medically exclusive with any other medical service code in the at least one claim; means for authorizing medical service codes which are not medically exclusive with any other medical service codes contained in the at least one claim in response to the means for determining; and means for rejecting medical service codes which are medically exclusive with any other medical service codes contained in the at least one claim in response to the determining step.

Claim 13

A computer system including a central processing unit and associated memory for processing input claims containing at least one medical service code, comprising: a predetermined database stored in the associated memory, the database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when received with other selected ones of the medical service codes; means for receiving at least one claim; means for determining whether any medical service code contained in the at least one claim is not present in the predetermined database; and means for informing a user that a medical service code is not contained in the predetermined database.

Claim 14

A computer system including a central processing unit and associated memory for processing input claims containing at least one medical service code, comprising: a predetermined database stored in the associated memory, the database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when received with other selected ones of the medical service codes; means for receiving at least one claim; means for ascertaining whether the at least one claim contains a plurality of medical service codes; means for determining whether one of the medical service codes in the at least one claim is mutually exclusive due to non-medical criteria with any other medical service code in the at least one claim; means for authorizing medical service codes which are not mutually exclusive due to non-medical criteria with any other medical service codes contained in the at least one claim in response to the means for determining; and means for rejecting medical service codes which are mutually exclusive due to non-medical criteria with any other medical service codes contained in the at least one claim in response to the means for determining.

Claim 15

A computer system including a central processing unit and associated memory for processing input claims containing at least one medical service code, comprising: a predetermined database stored in the associated memory, the database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when received with other selected ones of the medical service codes; means for receiving at least one claim; means for ascertaining whether the at least one claim contains a plurality of medical service codes; means for determining whether one of the medical service codes in the plurality of medical service codes is valid or invalid by interacting with the database and the set of relationships contained in the database; means for authorizing the at least one claim in response to the means for determining; and means for rejecting the at least one claim in response to the means for determining.

Claim 16

In a computer system having means for operating on a predetermined database containing medical service codes and a set of relationships among the medical service codes defining whether selected ones of the medical service codes are valid when input with other selected ones of the medical services codes, a method for processing input claims containing at least one medical service code, comprising the steps of: receiving at least one claim; ascertaining whether the at least one claim contains a plurality of medical service codes; determining whether one of the medical service codes in the plurality of medical service codes is valid or invalid by interacting with the database and the set of relationships contained in the database; authorizing the at least one claim in response to the determining step; and rejecting the at least one claim in response to the determining step.