Method and system for providing healthcare insurance

• US 20050251428A1
• Filed: 08/04/2004
• Published: 11/10/2005
• Est. Priority Date: 05/06/2004
• Status: Abandoned Application

• Current Assignee: David B. Cook, Hans F. Kraabel, Larry R. Dust, Wallace T. Gray
• Original Assignee: David B. Cook, Hans F. Kraabel, Larry R. Dust, Wallace T. Gray
• Inventors: Cook, David B., Dust, Larry R., Gray, Wallace T., Kraabel, Hans F.
• Application Number:
  US10/911,324
• Publication Number:
  US 20050251428A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/00 Administration; Management
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method and system for providing healthcare benefits according to the present invention may include a proposed healthcare plan having a primary component, a supplemental component, and a procedure for optimizing services consumption which is presented and customized “on-the-fly” to benefits providers, such as employers, and administered in an efficient manner that reduces the claims processing burden on individuals or families covered under the proposed plan.

Claims

1. A method demonstrating the affect of changes to a healthcare plan, including the steps of:

collecting information describing characteristics of a current plan;

inputting the information into a computing device having a display;

generating characteristics of a proposed plan, including a primary component and a supplemental component; and

displaying the characteristics of the proposed plan on the display.

2. The method of claim 1, further including the step of determining a savings level of the proposed plan relative to the current plan.

3. The method of claim 2, further including the steps of generating and displaying a modified proposed plan in response to the determining step.

4. The method of claim 1, wherein the characteristics of the proposed plan include a deductible, a coinsurance maximum, a coinsurance percentage, and an inpatient copayment.

5. The method of claim 1, wherein the characteristics of the current plan and the proposed plan each include a maximum out-of-pocket expense for an individual and a maximum out-of-pocket expense for a family.

6. The method of claim 5, wherein the individual maximum out-of-pocket expense is less under the proposed plan than under the current plan for an annual claims amount that is less than or equal to an average annual claims amount in the United States.

7. The method of claim 1, wherein the primary component of the proposed plan is self-funded.

8. The method of claim 1, wherein the primary component of the proposed plan is fully-insured.

9. The method of claim 1, wherein the primary component of the proposed plan, as compared to the current plan, represents a shift of cost from a benefits provider to a benefits recipient.

10. The method of claim 9, wherein the supplemental component of the proposed plan reduces the cost shift.

11. The method of claim 1, wherein the proposed plan includes cost projections over a time period that is greater than one year.

12. The method of claim 1, wherein the proposed plan includes cost projections over a three-year time period.

13. The method of claim 12, wherein cost projections associated with the primary component of the proposed plan are substantially constant over the three year period.

14. The method of claim 1, wherein the displaying step includes the step of displaying a savings amount of the proposed plan relative to the current plan expressed in dollars.

15. The method of claim 14, wherein the displaying step further includes the step of displaying a plurality of savings amounts of the proposed plan relative to the current plan, each savings amount being expressed in dollars and corresponding to a different one-year time period.

16. The method of claim 14, wherein the savings amount is also expressed as a percentage of a cost of the current plan.

17. The method of claim 1, wherein a cost of the proposed plan to a benefits recipient under the proposed plan is different for claims processed under the proposed plan in a first sequence than for the claims processed under the proposed plan in a second sequence that is different from the first sequence.

18. The method of claim 17, wherein a cost of the proposed plan to a benefits provider of the proposed plan is the same for the claims regardless of whether the claims are processed in the first sequence or the second sequence.

19. The method of claim 1, wherein, for a majority of benefits recipients under the proposed plan, a projected annual cost of the proposed plan is less than a projected annual cost of the current plan.

20. The method of claim 1, wherein a relativity factor of the proposed plan is less than a relativity factor of the current plan.

21. The method of claim 1, wherein the computing device is a laptop computer.

22. A method of providing healthcare benefits to a population of individuals who reside and consume healthcare services in a health economic zone, including the steps of

determining characteristics of a current plan for healthcare benefits;

designing a primary component that provides a decreased level of benefits to the individuals relative to the current plan;

designing a supplemental component that offsets at least a portion of the decreased level of benefits provided by the primary component;

identifying a first group of individuals from the population likely to generate expensive healthcare claims relative to other individuals in the population based on data representing past healthcare claims generated by the individuals in the population;

periodically determining whether individuals 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; and

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.

23. The method of claim 22, further including the step of

responding to healthcare requests from individuals in the population by determining whether an individual 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.

24. The method of claim 22, wherein the step of identifying a first group of individuals includes the step of identifying individuals suffering from one or more chronic illness.

25. The method of claim 22, wherein the step of identifying a first group of individuals includes the step of assigning a healthcare index to each individual based upon factors including age and gender of the individual.

26. The method of claim 22, wherein the step of identifying a first group of providers includes the steps of calculating a cost efficiency index of each provider in a health economic zone, and assigning a non-certified designation to each provider having cost efficiency index that fails to satisfy a first predetermined condition.

27. The method of claim 26, wherein the step of identifying a first group of providers includes the steps of determining a service rate for each provider, and assigning a non-certified designation to each provider having a service rate that fails to satisfy a second predetermined condition.

28. The method of claim 27, wherein the step of determining a service rate for each provider includes the step of evaluating the number and types of preventative care services ordered by each provider for the treatment of a chronic illness.

29. The method of claim 27, wherein the step of identifying a first group of providers includes the steps of evaluating the practice patterns of each provider, and assigning a non-certified designation to each provider having practice patterns that fail to satisfy a third predetermined condition.

30. The method of claim 29 wherein the step of identifying a first group of providers includes the steps of 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.

31. A structure for processing claims of employees covered under a healthcare plan having a primary component and a supplemental component, including:

a primary TPA who receives a claim from a healthcare provider, provides a primary payment to the provider based on characteristics of the primary component of the plan, and provides a primary EOB to an employee associated with the claim; and

a supplemental TPA who receives the primary EOB from the employee, provides a supplemental payment based on characteristics of the supplemental component of the plan, and provides a supplemental EOB to the employee.

32. The structure of claim 31, wherein the supplemental TPA provides the supplemental payment to the employee, who provides the supplemental payment to the provider.

33. The structure of claim 31, wherein the supplemental TPA provides the supplemental payment to the provider.

34. A structure for processing claims of employees covered under a healthcare plan having a primary component and a supplemental component, including:

a primary TPA who receives a claim from a healthcare provider, provides a primary payment to the provider based on characteristics of the primary component of the plan, and provides a primary EOB to an employee associated with the claim; and

a supplemental TPA who provides a supplemental payment based on characteristics of the supplemental component of the plan, and provides a supplemental EOB for communication to the employee;

wherein the primary TPA also provides a primary EOB to the supplemental TPA.

35. The structure of claim 34, wherein the primary EOB provided to the supplemental TPA by the primary TPA is an electronic transmission.

36. The structure of claim 34, wherein the supplemental TPA provides the supplemental payment to the employee.

37. The structure of claim 34, wherein the supplemental EOB is provided directly to the employee by the supplemental TPA.

38. The structure of claim 34, wherein the supplemental TPA provides the supplemental EOB to the primary TPA and the primary TPA simultaneously provides the primary EOB and the supplemental EOB to the employee.

39. The structure of claim 38, wherein the supplemental TPA provides the supplemental payment to the primary TPA and the primary TPA provides the supplemental payment to the employee with the primary and supplemental EOBs.

40. The structure of claim 34, wherein the supplemental component is self-funded by an employer who provides the healthcare plan.

41. A method of administering healthcare benefits to employees including the steps of:

providing a primary component of a healthcare plan which pays a first benefit as a result of a healthcare claim of an employee;

providing a supplemental component of the healthcare plan which pays a second benefit as a result of the healthcare claim if the first benefit does not satisfy the claim;

providing a flexible spending account; and

withdrawing available funds from the flexible spending account if payment of the second benefit does not satisfy the claim.

42. The method of claim 41, further including the steps of:

generating a primary EOB relating to payment of the first benefit;

generating a supplemental EOB relating to payment of the second benefit; and

forwarding the primary EOB, the supplemental EOB and the available funds to the employee.

43. The method of claim 41, wherein a supplemental TPA administers the supplemental component and withdraws the available funds from the flexible spending account.

44. The method of claim 41, wherein a TPA administers the primary component and the supplemental component of the healthcare plan.

45. A system for demonstrating the affect of changes to a healthcare plan, including:

a computing device having an input device and a display; and

software configured for operation on the computing device, wherein the software enables a user to input information describing characteristics of a current plan into the computing device via the input device, enables the computing device to generate characteristics of a proposed plan, including a primary component and a supplemental component, and enables the computing device to display the characteristics of the proposed plan on the display in a format showing a cost savings of implementing the proposed plan, relative to a cost of the current plan.

46. A method of administering healthcare benefits to employees including the steps of:

providing a primary component of a healthcare plan which pays a first benefit as a result of a healthcare claim of an employee;

providing a supplemental component of the healthcare plan which pays a second benefit as a result of the healthcare claim if the first benefit does not satisfy the claim;

providing a benefit bank corresponding to the employee, the benefit bank including funds available to the employee to purchase other benefits as selected by the employee.

47. The method of claim 46, wherein a portion of the funds included in the benefit bank are provided by the employer.

48. The method of claim 47, wherein the portion of the funds corresponds to a cost savings to the employer resulting from adoption of the healthcare plan as compared to a current plan of the employer.

49. The method of claim 46, wherein the other benefits include insurance products.

50. The method of claim 46, wherein the benefit bank is accessible by the employee over the internet.

51. A method demonstrating the affect of changes to a healthcare plan, including the steps of:

collecting historical healthcare claims data;

calculating an actual cost associated with the historical healthcare claims data during a previous time period;

generating characteristics of a proposed plan, including a primary component and a supplemental component;

applying the proposed plan characteristics to the historical claims data to determine a second cost that would have been associated with the historical claims data under the proposed plan; and

displaying on a display a comparison of the actual cost to the second cost.

52. The method of claim 51, wherein the characteristics of the proposed plan include a deductible, a coinsurance maximum, a coinsurance percentage, and an inpatient copayment.