Computerized system and methods for adjudicating and reimbursing for healthcare services based on quality
First Claim
1. A method in a computing environment for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:
- receiving a transaction including a number of clinical event details for the clinical event;
accessing a first knowledge base comprising a number of criteria for assessing quality of care;
selecting at least one appropriate criterion based on the clinical event details;
performing analysis of the clinical event details against the selected at least one criterion to determine the quality of care; and
determining a level of reimbursement based on the quality of care.
1 Assignment
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Accused Products
Abstract
A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate. The method further includes the steps of accessing a second knowledge base containing at least one criterion for assessing quality of care and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine if the care provided is medically appropriate. Also, the method includes determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.
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Citations
12 Claims
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1. A method in a computing environment for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:
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receiving a transaction including a number of clinical event details for the clinical event;
accessing a first knowledge base comprising a number of criteria for assessing quality of care;
selecting at least one appropriate criterion based on the clinical event details;
performing analysis of the clinical event details against the selected at least one criterion to determine the quality of care; and
determining a level of reimbursement based on the quality of care. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12)
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Specification