Method of optimizing healthcare services consumption
First Claim
1. A method of optimizing healthcare services consumption, including the steps of:
- assessing a healthcare situation of an employer who provides healthcare benefits to a population that resides and consumes healthcare services in a health economic zone;
identifying a first group of patients from the population likely to generate expensive healthcare claims relative to other patients in the population based on data representing past healthcare claims generated by the population;
periodically determining whether patients in the first group have obtained healthcare services that satisfy predetermined requirements;
identifying a first group of providers in the health economic zone who provide high quality, cost efficient healthcare services relative to other providers in the health economic zone based on data representing past practice patterns of the first group of providers and the other providers;
prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers in the first group of providers; and
responding to healthcare requests from the population by determining whether a patient submitting the request is seeking to obtain healthcare services from a provider in the first group of providers, and, if not, urging the submitting patient to obtain healthcare services from a provider in the first group of providers.
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Accused Products
Abstract
A method of optimizing healthcare services consumption according to the invention includes the steps of assessing the healthcare situation of an employer providing healthcare benefits to a population, identifying a first group of patients from the population likely to generate expensive healthcare claims based on data representing past claims, periodically determining whether patients in the first group have satisfied certain predetermined healthcare requirements, identifying a first group of providers who provide high quality, cost efficient healthcare services based on the practice patterns of the providers, prompting patients who have not satisfied the predetermined healthcare requirements to obtain services from providers in the first group, and responding to healthcare requests from patients by determining whether the requesting patient is seeking services from a provider in the first group, and, if not, urging the patient to obtain such services from a provider in the first group.
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Citations
51 Claims
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1. A method of optimizing healthcare services consumption, including the steps of:
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assessing a healthcare situation of an employer who provides healthcare benefits to a population that resides and consumes healthcare services in a health economic zone;
identifying a first group of patients from the population likely to generate expensive healthcare claims relative to other patients in the population based on data representing past healthcare claims generated by the population;
periodically determining whether patients in the first group have obtained healthcare services that satisfy predetermined requirements;
identifying a first group of providers in the health economic zone who provide high quality, cost efficient healthcare services relative to other providers in the health economic zone based on data representing past practice patterns of the first group of providers and the other providers;
prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers in the first group of providers; and
responding to healthcare requests from the population by determining whether a patient submitting the request is seeking to obtain healthcare services from a provider in the first group of providers, and, if not, urging the submitting patient to obtain healthcare services from a provider in the first group of providers. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24)
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25. A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer and administered by a healthcare quality management firm in a health economic zone that corresponds to the residences of the patients and the locations of providers used by the patients, the method including the steps of:
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ranking providers in the health economic zone based on an analysis of the quality and cost efficiency of practice patterns associated with the providers;
dividing the ranking of providers into a first level of providers, a second level of providers, and a third level of providers;
responding to a healthcare request from a patient by determining the level into which the provider associated with the request falls;
urging the patient to use a first level provider if the associated provider is a second or a third level provider;
urging the patient to use a second level provider if the associated provider is a third level provider;
conducting a first set of intervention actions corresponding to a first degree of involvement of the healthcare quality management firm in the provision of services by the provider used by the patient if the used provider is a second level provider; and
conducting a second set of intervention actions corresponding to a second degree of involvement of the healthcare quality management firm in the provision of services by the used provider if the used provider is a third level provider, the second degree of involvement being greater than the first degree of involvement. - View Dependent Claims (26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36)
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37. A method of optimizing healthcare services consumption by patients of a population in a healthcare plan provided by an employer, the method including the steps of:
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calculating a cost efficiency index of each healthcare provider in a health economic zone based upon past claims information;
assigning a non-certified designation to each provider having cost efficiency index that fails to satisfy a first predetermined condition;
determining a service rate for each provider based upon the past claims information;
assigning a non-certified designation to each provider having a service rate that fails to satisfy a second predetermined condition;
evaluating practice patterns of each provider based upon the past claims information;
assigning a non-certified designation to each provider having practice patterns that fail to satisfy a third predetermined condition;
assigning a qualified designation to each provider having a cost efficiency index, a service rate, and practice patterns that satisfy the first, second, and third predetermined conditions, respectively; and
responding to a request from an patient for healthcare services by urging the patient to obtain the services from a provider having a qualified designation. - View Dependent Claims (38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48)
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49. A method of optimizing health services consumption of patients in a healthcare plan administered within a geographic area, the method including the steps of:
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ranking providers located in the geographic area based on an analysis of the quality and cost efficiency of practice patters associated with the providers;
dividing the ranking of providers into a first level of providers and a second level of providers;
responding to a healthcare request from a patient requesting services from a second level provider by accessing the ranking of providers to identify providers having a first level ranking located within a selectable distance from the patient. - View Dependent Claims (50, 51)
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Specification