System and method for ensuring medical benefit claim payment neutrality between different disease classification codes

• US 10,607,733 B2
• Filed: 06/16/2014
• Issued: 03/31/2020
• Est. Priority Date: 06/14/2013
• Status: Active Grant

• Current Assignee: Atos France
• Original Assignee: Syntec Incorporated (Atos SE)
• Inventors: Reddy, Murlidhar
• Primary Examiner(s): Nguyen, Hiep V
• Application Number:
  US14/306,208
• Publication Number:
  US 20140372142A1
• Time in Patent Office: 2,115 Days
• Field of Search: 705 2
• CPC Class Codes: G06F 8/30 Creation or generation of source code
• CPC Class Codes: G06F 8/70 Software maintenance or management
• CPC Class Codes: G06Q 50/22 Social work or social welfare, e.g. community support activities or counselling services
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 70/60 relating to pathologies

Abstract

A neutrality analysis system includes receives existing claim data including at least one existing healthcare code associated with a first classification system, receives new claim data including a plurality of new healthcare codes associated with a second classification system, wherein the at least one existing healthcare code is mapped to the at least one new healthcare code, receives a plurality of payment codes associated with the at least one existing healthcare code and the at least one new healthcare code, and based on the received plurality of payment codes, calculates payments of the received existing and new claim data, respectively, and based on the calculating, selects a financially neutral new healthcare code of the plurality of new healthcare codes.

Claims

1. A computerized method comprising:

receiving existing claim data including at least one existing healthcare code associated with a first classification system;

receiving new claim data including at least one new healthcare code associated with a second classification system, wherein the at least one existing healthcare code is mapped to the at least one new healthcare code;

receiving a plurality of payment codes associated with the at least one existing healthcare code and the at least one new healthcare code;

converting, using a processor, a one-to-many mapping from said at least one existing healthcare code associated with the first classification system to a plurality of said new healthcare codes associated with the second classification system, to a corresponding plurality of one-to-one mappings from said at least one existing healthcare code associated with the first classification system to one of said plurality of said new healthcare codes associated with the second classification system;

based upon the plurality of one-to-one mappings and the plurality of payment codes, generating a test case, the test case defined by at least one payment variance threshold and at least one benefit variance threshold;

based on the received plurality of payment codes, calculating payments and benefits of the received existing and new claim data, respectively, wherein the calculating payments further comprises calculating a respective variance between the calculated payments and benefits of the received existing and new claim data;

executing the test case to determine whether the calculated payment variance exceeds the at least one payment variance threshold, wherein if the calculated payment variance exceeds the at least one payment variance threshold, the test case is further executed to determine an allowed amount variance and a paid amount variance;

executing the test case to determine whether the calculated benefit variance between the calculated benefits of the received existing and new claim data exceeds the at least one benefit variance threshold; and

providing a user interface configured to receive a user selection of a financially neutral new healthcare code of the at least one new healthcare codes, wherein providing the user interface comprises;

based upon the calculation of the payment variance, identifying the at least one existing healthcare code or the at least one new healthcare code causing the payment variance;

based upon historical user selection information, identifying the most used new healthcare code identified by the one-to-one mappings; and

generating a report comprising;

(i) the identification of the at least one existing healthcare code or the at least one new healthcare code causing the payment variance; and

(ii) the most used new healthcare code identified by the one-to-one mappings.

2. The computerized method of claim 1, wherein the payments comprise an amount a healthcare provider is allowed to receive for a rendered service.

3. The computerized method of claim 1, wherein the payments comprise an amount paid by an insured patient for receiving a service from a healthcare provider, wherein the insured patient is associated with the existing and new claim data.

4. The computerized method of claim 1, wherein the calculating further comprises calculating payments of the received existing and new claim data with respect to an age of an insured patient associated with the existing and new claim data.

5. The computerized method of claim 1, wherein the calculating the payment variance is with respect to an age of an insured patient associated with the existing and new claim data.

6. The computerized method of claim 1, wherein the plurality of payment codes are diagnosis related group (“

DRG”

) codes.

7. The computerized method of claim 1, wherein if the calculated variance between the calculated benefits of the received existing and new claim data exceeds the at least one benefit variance threshold, the test case is further executed to determine a deductible variance, a gender restriction variance, and an age limitation variance.

8. The computerized method of claim 7, wherein based upon the calculation of the benefits variance, identifying the at least one existing healthcare code or the at least one new healthcare code causing the benefits variance.

9. The computerized method of claim 8, the generating a report further comprising the identification of the at least one existing healthcare code or the at least one new healthcare code causing the benefit variance.

10. A system comprising:

one or more computing devices including;

a memory having program code stored therein;

a processor in communication with the memory for carrying out instructions in accordance with the stored program code, wherein the program code, when executed by the processor, causes the processor to perform steps comprising;

receiving existing claim data including at least one existing healthcare code associated with a first classification system;

receiving new claim data including a plurality of new healthcare codes associated with a second classification system, wherein the at least one existing healthcare code is mapped to the at least one new healthcare code;

receiving a plurality of payment codes associated with the at least one existing healthcare code and the at least one new healthcare code;

converting, using a processor, a one-to-many mapping from said at least one existing healthcare code associated with the first classification system to a plurality of said new healthcare codes associated with the second classification system, to a corresponding plurality of one-to-one mappings from said at least one existing healthcare code associated with the first classification system to one of said plurality of said new healthcare codes associated with the second classification system;

based upon the plurality of one-to-one mappings and the plurality of payment codes, generating a test case, the test case defined by at least one payment variance threshold and at least one benefit variance threshold;

based on the received plurality of payment codes, calculating payments and benefits of the received existing and new claim data, respectively, wherein the calculating payments further comprises calculating a respective variance between the calculated payments and benefits of the received existing and new claim data;

executing the test case to determine whether the calculated payment variance exceeds the at least one payment variance threshold, wherein if the calculated payment variance exceeds the at least one payment variance threshold, the test case is further executed to determine an allowed amount variance and a paid amount variance;

executing the test case to determine whether the calculated benefit variance between the calculated benefits of the received existing and new claim data exceeds the at least one benefit variance threshold; and

providing a user interface configured to receive a user selection of a financially neutral new healthcare code of the at least one new healthcare codes, wherein providing the user interface comprises;

based upon the calculation of the payment variance, identifying the at least one existing healthcare code or the at least one new healthcare code causing the payment variance;

based upon historical user selection information, identifying the most used new healthcare code identified by the one-to-one mappings; and

generating a report comprising;

(i) the identification of the at least one existing healthcare code or the at least one new healthcare code causing the payment variance; and

(ii) the most used new healthcare code identified by the one-to-one mappings.

11. The system of claim 10, wherein the payments comprise an amount a healthcare provider is allowed to receive for a rendered service.

12. The system of claim 10, wherein the payments comprise an amount paid by an insured patient for receiving a service from a healthcare provider, wherein the insured patient is associated with the existing and new claim data.

13. The system of claim 10, wherein the calculating further comprises calculating payments of the received existing and new claim data with respect to an age of an insured patient associated with the existing and new claim data.

14. The system of claim 10, wherein the calculating the payment variance is with respect to an age of an insured patient associated with the existing and new claim data.

15. The system of claim 10, wherein the plurality of payment codes are diagnosis related group (“

DRG”

) codes.

16. A non-transitory computer readable medium upon which is embodied a sequence of programmed instructions which, when executed by a processor, cause the processor to perform steps comprising:

receiving existing claim data including at least one existing healthcare code associated with a first classification system;

receiving new claim data including a plurality of new healthcare codes associated with a second classification system, wherein the at least one existing healthcare code is mapped to the at least one new healthcare code;

receiving a plurality of payment codes associated with the at least one existing healthcare code and the at least one new healthcare code;

converting, using a processor, a one-to-many mapping from said at least one existing healthcare code associated with the first classification system to a plurality of said new healthcare codes associated with the second classification system, to a corresponding plurality of one-to-one mappings from said at least one existing healthcare code associated with the first classification system to one of said plurality of said new healthcare codes associated with the second classification system;

based upon the plurality of one-to-one mappings and the plurality of payment codes, generating a test case, the test case defined by at least one payment variance threshold and at least one benefit variance threshold;

based on the received plurality of payment codes, calculating payments and benefits of the received existing and new claim data, respectively, wherein the calculating payments further comprises calculating a respective variance between the calculated payments and benefits of the received existing and new claim data; and

executing the test case to determine whether the calculated payment variance exceeds the at least one payment variance threshold, wherein if the calculated payment variance exceeds the at least one payment variance threshold, the test case is further executed to determine an allowed amount variance and a paid amount variance;

executing the test case to determine whether the calculated benefit variance between the calculated benefits of the received existing and new claim data exceeds the at least one benefit variance threshold; and

providing a user interface configured to receive a user selection of a financially neutral new healthcare code of the at least one new healthcare codes, wherein providing the user interface comprises;

based upon the calculation of the payment variance, identifying the at least one existing healthcare code or the at least one new healthcare code causing the payment variance;

based upon historical user selection information, identifying the most used new healthcare code identified by the one-to-one mappings; and

generating a report comprising;

(i) the identification of the at least one existing healthcare code or the at least one new healthcare code causing the payment variance; and

(ii) the most used new healthcare code identified by the one-to-one mappings.

17. The non-transitory computer readable medium of claim 16, wherein the payments comprise an amount a healthcare provider is allowed to receive for a rendered service.

18. The non-transitory computer readable medium of claim 16, wherein the payments comprise an amount paid by an insured patient for receiving a service from a healthcare provider, and wherein the insured patient is associated with the existing and new claim data.

19. The non-transitory computer readable medium of claim 16, further comprising calculating payments of the received existing and new claim data with respect to an age of an insured patient associated with the existing and new claim data.

20. The non-transitory computer readable medium of claim 16, wherein the calculating the payment variance is with respect to an age of an insured patient associated with the existing and new claim data.