Preadmission health care cost and reimbursement estimation tool

• US 20060080139A1
• Filed: 10/08/2004
• Published: 04/13/2006
• Est. Priority Date: 10/08/2004
• Status: Abandoned Application

• Current Assignee: Woodhaven Health Services
• Original Assignee: Woodhaven Health Services
• Inventors: Mainzer, Richard
• Application Number:
  US10/960,758
• Publication Number:
  US 20060080139A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

A cost estimation tool, preferably a handheld computer, prices and evaluates the financial impact of new residents'"'"' prior to admission. Immediate access to this information and built-in therapeutic substitution and clinical advisories provides the opportunity to optimize pharmaceutical regimens prior to admission. In addition, an abbreviated Resource Utilization Group (RUG) evaluation function provides a rapid assessment tool to project reimbursement under the Medicare Prospective Payment System (PPS). A user may enter a complete drug regimen and estimate the costs for the regimen. Similarly, managed care reimbursement from managed care organizations (MCOs) to be analyzed. Also, drug cost may be estimated through a MEDICAID Preferred Drug List database that identifies potential Non-Preferred drugs that may be non-compensable. The present invention further transmits results wirelessly to health care providers.

Claims

1. A method for estimating treatment costs for patient, the method comprising the steps of:

collecting patient data and storing the patient data on a computer;

the computer defining reimbursement coverage using collected patient data;

defining a course of treatment using collected patient data and storing the course of treatment on the computer; and

the computer pricing the course of treatment using reimbursement data,

wherein said steps of collecting patient data, defining reimbursement coverage, defining a course of treatment, and, pricing the course of treatment occur prior to admission.

2. The method of claim 1 further comprising the step of the computer forwarding the course of treatment and the course of treatment pricing to a health care provider.

3. The method of claim 1, wherein the step of defining reimbursement coverage comprises determining the patient'"'"'s eligibility for at one of health insurance, Medicare, and Medicaid.

4. The method of claim 3, wherein the patient is eligible for Medicaid, and wherein the step of defining reimbursement coverage comprising identifying a preferred drug list (PDL).

5. The method of claim 3, wherein the step of defining reimbursement coverage comprising identifying a Medicare Resource Utilization Group (RUG) for the patient.

6. The method of claim 5, wherein the step of collecting patient data comprises scoring the patient in one or more activities of daily living (ADLs), whereby said scoring is used to identify the RUG for the patient.

7. The method of claim 1, wherein the step of defining a course of treatment comprises specifying a regimen including one or more drugs.

8. The method of claim 1 wherein the step of defining a course of treatment comprises defining a first course of treatment, wherein the step of pricing the course of treatment comprises pricing the first course of treatment, and wherein the method further comprises the steps of:

modifying the first course of treatment to define a second course of treatment;

the computer pricing the second course of treatment; and

the computer comparing the price for the first course of treatment and the price for the second course of treatment.

9. A data storage medium containing a computer-executable set of instructions for estimating patient costs, the set of instructions implementing a process comprising:

collecting patient data;

defining reimbursement coverage using collected patient data;

defining a course of treatment using collected patient data; and

pricing the course of treatment using reimbursement data,

wherein said steps of collecting patient data, defining reimbursement coverage, defining a course of treatment, and, pricing the course of treatment occur prior to admission.

10. The data storage medium of claim 9 wherein the process further comprises the step of the computer forwarding the course of treatment and the course of treatment pricing to a health care provider.

11. The data storage medium of claim 9, wherein the step of defining reimbursement coverage comprises determining the patient'"'"'s eligibility for at one of health insurance, Medicare, and Medicaid.

12. The data storage medium of claim 11, wherein the step of defining reimbursement coverage comprising designating the patient as eligible for Medicaid and identifying a preferred drug list (PDL).

13. The data storage medium of claim 12, wherein the step of defining a course of treatment comprises specifying a proposed regimen including one or more drugs, and wherein the process further comprises the steps of:

determining whether the proposed regimen conforms with the PDL;

and for a non conforming regimen, proposing an alternative regimen conforming with the PDL.

14. The data storage medium of claim 11, wherein the step of defining reimbursement coverage comprising identifying a Medicare Resource Utilization Group (RUG) for the patient.

15. The data storage medium of claim 14, wherein the step of collecting patient data comprises scoring the patient in one or more activities of daily living (ADLs), whereby said scoring is used to identify the RUG for the patient.

16. The data storage medium of claim 9, wherein the step of defining a course of treatment comprises specifying a regimen including one or more drugs.

17. The data storage medium of claim 9, wherein the step of defining a course of treatment comprises defining a first course of treatment, wherein the step of pricing the course of treatment comprises pricing the first course of treatment, and wherein the process further comprises the steps of:

modifying the first course of treatment to define a second course of treatment;

the pricing the second course of treatment; and

comparing the price for the first course of treatment and the price for the second course of treatment.

18. A preadmission patient cost estimation tool comprising:

an input device for specifying patient data and a course of treatment prior to patient admission;

a first logic for defining a patient coverage category by comparing said patient data to a coverage database containing eligibility rules for one or more coverage categories and reimbursement rules associated with each of said coverage categories;

a second logic for pricing the course of treatment using the reimbursement rules for the defined patient coverage category; and

a patient data database for storing said patient data, said course of treatment, said defined patient coverage category, and said pricing for the course of treatment.

19. The preadmission patient cost estimation tool of claim 18 further comprising a network connected to said patient database, wherein said network allows a health care provider to access said patient database.

20. The preadmission patient cost estimation tool of claim 18, wherein the coverage categories comprises at one of private health insurance, Medicare, and Medicaid.

21. The preadmission patient cost estimation tool of claim 20, wherein the patient coverage category is Medicaid, and wherein the associated reimbursement rules identify a preferred drug list (PDL).

22. The preadmission patient cost estimation tool of claim 21, wherein the defined course of treatment comprises a proposed regimen including one or more drugs, and wherein the tool further comprises logic for determining whether the proposed regimen conforms with the PDL and for proposing an alternative regimen conforming with the PDL.

23. The preadmission patient cost estimation tool of claim 18, wherein the first logic for defining a patient coverage identifies a Medicare Resource Utilization Group (RUG) for the patient.

24. The preadmission patient cost estimation tool of claim 23, wherein the first logic further comprises a RUGS estimation tool.

25. The preadmission patient cost estimation tool of claim 24, wherein the RUGS estimation tool scores the patient in one or more activities of daily living (ADLs) using the patient data, wherein said scoring is used to identify the patient RUG.

26. The preadmission patient cost estimation tool of claim 18, wherein the course of treatment comprises a regimen including one or more drugs.

27. The preadmission patient cost estimation tool of claim 18, wherein:

the course of treatment comprises first course of treatment,

the pricing of the course of treatment comprises pricing of the first course of treatment,

the input device is used to define a second course of treatment;

the second logic prices the second course of treatment using the reimbursement rules for the defined patient coverage category, and

the second logic compares the price for the first course of treatment and the price for the second course of treatment.