METHOD AND SYSTEM FOR ESTIMATING THE FINANCIAL LIABILITY OF A PATIENT FOR A MEDICAL SERVICE

• US 20070271119A1
• Filed: 04/30/2007
• Published: 11/22/2007
• Est. Priority Date: 05/01/2006
• Status: Active Grant

• Current Assignee: Change Healthcare Holdings, LLC (UnitedHealth Group Incorporated)
• Original Assignee: Envoy LLC (UnitedHealth Group Incorporated)
• Inventors: KULKARNI, Jaideep, PACE, Geoff, BOERGER, Gene, HARDIN, Philip
• Granted Patent: US 8,645,162 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time 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 computer implemented method involving a medical service for a patient includes estimating an expected payment associated with the medical service for the patient based on a set of data including payments for similar medical services provided to a population of individuals. The method also includes estimating a cost expected to be borne by the patient for incurring the medical service based on the estimated expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient. The method further includes presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service.

Claims

1. A computer implemented method, comprising:

accessing a first data set including established payments that medical service providers have agreed to be paid by healthcare coverage entities for providing medical services to individuals;

determining if the first data set includes a specific established payment that a medical service provider of a patient has agreed to be paid by a healthcare coverage entity of the patient for a medical service provided to the patient;

if the first data set includes the specific established payment, returning the specific established payment for the medical service as an expected payment associated with the medical service;

if the first data set does not include the specific established payment, accessing a second data set including historical payments made by healthcare coverage entities to medical service providers for medical services provided to a population of individuals;

estimating the expected payment associated with the medical service for the patient based on the historical payments;

estimating a cost expected to be borne by the patient for incurring the medical service based on the expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient; and

presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service.

2. The method of claim 1, wherein the second data set includes a sufficient quantity of historical payments to enable a reliable estimate of the expected payment associated with the medical service to be made.

3. The method of claim 1, further comprising:

determining if the second data set includes a first set of specific historical payments that the medical service provider of a patient has been paid by the healthcare coverage entity of the patient for medical services provided to the population of individuals that are similar to the medical service for the patient;

if the second data set includes the first set of specific historical payments, the estimating the expected payment associated with the medical service for the patient is based on the first set of specific historical payments;

if the second data set does not include the first set of specific historical payments, determining if the second data set includes a second set of specific historical payments that medical service providers sharing a similar classification as the medical service provider of a patient have been paid by the healthcare coverage entity of the patient for medical services provided to the population of individuals that are similar to the medical service for the patient; and

if the second data set includes the second set of specific historical payments, the estimating the expected payment associated with the medical service for the patient is based on the second set of specific historical payments.

4. The method of claim 3, wherein at least one of the first set of specific historical payments and the second set of historical payments includes a sufficient quantity of historical payments to enable a reliable estimate of the expected payment associated with the medical service to be made.

5. The method of claim 3, wherein the similarity of classification is based on at least one of a geographic location of the medical service providers, a specialty of the medical service providers, and a type of facility of the medical service providers.

6. The method of claim 1, wherein the healthcare coverage entity of the patient is at least one of a commercial insurer, a government insurer, a third party administrator, an employer, an employer group, a pharmaceutical benefits manager, and a health maintenance organization.

7. The method of claim 1, wherein the second data set is based on adjudicated medical claims.

8. The method of claim 1, wherein the set of parameters associated with the healthcare coverage plan of the patient includes at least one of a co-pay amount, a co-insurance value, a deductible threshold, a lifetime benefits maximum payout value, a patient out-of-pocket total maximum amount, and a healthcare payer total benefits payment amount.

9. The method of claim 1, wherein the medical service for the patient includes more than one medical procedure and wherein at least one of the returning the specific established payment or the estimating the expected payment includes determining expected payments associated with the more than one medical procedure and wherein estimating the cost expected to be borne by the patient is based on the expected payments associated with the more than one medical procedure.

10. A computer implemented method involving a medical service for a patient, comprising:

estimating an expected payment associated with the medical service for the patient based on a set of data including payments for similar medical services provided to a population of individuals;

estimating a cost expected to be borne by the patient for incurring the medical service based on the estimated expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient; and

presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service.

11. The method of claim 10, wherein the set of data includes a sufficient quantity of payments to enable a reliable estimate of the expected payment associated with the medical service to be made.

12. The method of claim 10, wherein the population of individuals and the patient have a same healthcare coverage entity at the time each was provided the medical service.

13. The method of claim 12, wherein the healthcare coverage entity is at least one of a commercial insurer, a government insurer, a third party administrator, an employer, an employer group, a pharmaceutical benefits manager, and a health maintenance organization.

14. The method of claim 12, wherein the medical service for the population of individuals and the patient is provided by a same medical service provider.

15. The method of claim 12, wherein the medical service for the population of individuals and the patient is provided by medical service providers that share a similar classification.

16. The method of claim 15, wherein the similarity of classification is based on at least one of a geographic location of the medical service providers, a specialty of the medical service providers, and a type of facility of the medical service providers.

17. The method of claim 10, wherein estimating the expected payment occurs after determining that an established expected payment associated with the medical service is not available.

18. The method of claim 10, wherein the set of data including payments for similar medical services provided to the population of individuals is based on adjudicated medical claims.

19. The method of claim 18, wherein the adjudicated medical claims are for payments for medical services incurred by individuals having a same healthcare coverage entity as the patient.

20. The method of claim 19, wherein the adjudicated medical claims are for payments for medical services provided to the individuals by a same medical service provider providing the medical service to the patient.

21. The method of claim 10, wherein the set of parameters associated with the healthcare coverage plan of the patient includes at least one of a co-pay amount, a co-insurance value, a deductible threshold, a lifetime benefits maximum payout value, a patient out-of-pocket total maximum amount, and a healthcare payer total benefits payment amount.

22. The method of claim 10, wherein the medical service includes more than one medical procedure and wherein estimating the expected payment includes estimating expected payments associated with the more than one medical procedure and wherein estimating the cost expected to be borne by the patient is based on the expected payments associated with the more than one medical procedure.

23. A system comprising:

a computer system;

program code on a computer-readable medium, which when executed on the computer system performs functions including;

estimating an expected payment associated with a medical service for a patient based on a set of data including payments for similar medical services provided to a population of individuals;

estimating a cost expected to be borne by the patient for incurring the medical service based on the estimated expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient; and

presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service.

24. The system of claim 23, further comprising an output device, wherein the presenting financial information is through the output device.

25. The system of claim 23, wherein the set of data includes a sufficient quantity of payments to enable a reliable estimate of the expected payment associated with the medical service to be made.

26. The system of claim 23, wherein the population of individuals and the patient have a same healthcare coverage entity at the time each was provided the medical service.

27. The system of claim 26, wherein the healthcare coverage entity is at least one of a commercial insurer, a government insurer, a third party administrator, an employer, an employer group, a pharmaceutical benefits manager, and a health maintenance organization.

28. The system of claim 26, wherein the medical service for the population of individuals and the patient is provided by a same medical service provider.

29. The system of claim 26, wherein the medical service for the population of individuals and the patient is provided by medical service providers that share a similar classification.

30. The method of claim 29, wherein the similarity of classification is based on at least one of a geographic location of the medical service providers, a specialty of the medical service providers, and a type of facility of the medical service providers.

31. The system of claim 23, wherein estimating the expected payment occurs after determining that an established expected payment associated with the medical service is not available.

32. The system of claim 23, wherein the set of data including payments for similar medical services provided to the population of individuals is based on adjudicated medical claims.

33. The system of claim 32, wherein the adjudicated medical claims are for payments for medical services incurred by individuals having a same healthcare coverage entity as the patient.

34. The system of claim 33, wherein the adjudicated medical claims are for payments for medical services provided to the individuals by a same medical service provider providing the medical service to the patient.

35. The system of claim 23, wherein the set of parameters associated with the healthcare coverage plan of the patient includes at least one of a co-pay amount, a co-insurance value, a deductible threshold, a lifetime benefits maximum payout value, a patient out-of-pocket total maximum amount, and a healthcare payer total benefits payment amount.

36. The system of claim 23, wherein the medical service includes more than one medical procedure and wherein estimating the expected payment includes estimating expected payments associated with the more than one medical procedure and wherein estimating the cost expected to be borne by the patient is based on the expected payments associated with the more than one medical procedure.