Computer-implemented method for grouping medical claims with clinically representative dynamic clean periods

Abstract

A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

Description

REFERENCE TO RELATED APPLICATIONS [0001] This application is a continuation of U.S. patent application Ser. No. 10 / 106,281, filed on Mar. 25, 2002, which is a divisional application of U.S. patent application Ser. No. 09 / 188,986 filed Nov. 9, 1998, which is a continuation patent application of U.S. patent application Ser. No. 08 / 493,728, filed on Jun. 22, 1995, issued as U.S. Pat. No. 5,835,897 on Nov. 10, 1998.FIELD OF THE INVENTION [0002] The present invention relates generally to computer-implemented methods for processing medical claims information. More particularly, the present invention relates to a computer-implemented method for receiving input data relating to a person's medical claim, establishing a management record for the person, establishing episode treatment groups to define groupings of medical episodes of related etiology, correlating subsequent medical claims events to an episode treatment group and manipulating episode treatment groups based upon time windows for...

AI Technical Summary

Benefits of technology

"The present invention provides a computer-implemented medical claims profiling system that allows for objective measurement and quantification of health care services. The system uses service or segment-level claim data as input data and assigns each service to an appropriate episode treatment group. The system can identify concurrent and recurrent episodes, and shifts the patient's episode from the initially defined group if there is a change in the patient's condition. The system can also compare the financial and clinical performance of individual providers or entire networks. The system includes an ETG grouper method that uses service or segment-level claim data as input data and assigns each service to the appropriate episode treatment group. The system can identify all providers treating a single illness episode and uncover specific treatment patterns. The system can also flag and log invalid records and identify anchor records. The technical effects of the invention include improved data accuracy, improved data analysis, and improved health care management."

Problems solved by technology

Because of the complex nature of medical care service data, many clinicians and administrators are not able to efficiently utilize the data.

Systems that detect inappropriate coding, eliminate potentially inappropriate services or conduct encounter-based payment methodology are insufficient for correcting the inconsistencies of the health care system.

When a complication or comorbidity is encountered during the course of treatment, many systems do not reclassify the treatment profile.

Existing systems do not adjust for casemix, concurrent conditions or recurrent conditions.

When profiling claims, existing systems establish classifications that do not contain a manageable number of groupings, are not clinically homogeneous or are not statistically stable.

While the PEER-A-MED system contains clinically heterogeneous groupings, the groupings are not episode-based and recurrent episodes cannot be accounted.

Because different diseases could be categorized into the same ACG, this system is not clinically homogeneous.

An additional problem with ACGs is that too many diagnosis groups are in each ACG.

This system mainly analyzes outpatient hospital visits and does not address inpatient services.

This system does not link signs and symptoms and the diagnoses are non-comprehensive because the profiling is based on the exclusion of services.

The medical claim profiling programs described in foregoing patents and non-patent literature demonstrate that, while conventional computer-implemented health care systems exist, they each suffer from the principal disadvantage of not identifying and grouping medical claims on an episodic basis or shifting episodic groupings based upon complications or co-morbidities.

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