Computerized system and methods for adjudicating and reimbursing for healthcare services based on quality

• US 20060265251A1
• Filed: 01/06/2006
• Published: 11/23/2006
• Est. Priority Date: 01/06/2005
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Patterson, Neal L.
• Granted Patent: US 7,801,744 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• 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

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.

Claims

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.

2. The method according to claim 1, further comprising accessing a data store including EHR data elements.

3. The method according to claim 2, wherein the step of selecting at least one appropriate criteria is further based on EHR data elements.

4. The method according to claim 1, further comprising accessing a data store including a number of pre-existing transactions.

5. The method according to claim 4, further comprising selecting a number of pre-existing transactions based on the clinical event details.

6. The method according to claim 5, wherein the step of determining the quality of care and level of reimbursement based on the selected pre-existing transactions.

7. The method according to claim 1, further comprising accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer.

8. The method according to claim 1, further comprising accessing a second knowledge base comprising evidence-based options for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one option from the first knowledge base to determine if the care provided is medically appropriate.

9. The method according to claim 1, further comprising authorizing reimbursement of the care provider from the at least one payer.

10. The method according to claim 1, wherein the criteria consist of one or more of mortality, morbidity, length of visit or stay, onset of another condition due to poor care, recurrence, elimination of presenting problem, quality of life indicators, and patient satisfaction, and unplanned visits due to poor care.

11. The method according to claim 1, further comprising reimbursing the provider in real-time.

12. The method according to claim 1, wherein the clinical event details are documented as part of the provision of care.