METHODS, PROGRAM PRODUCT, AND SYSTEMS FOR HEALTHCARE PRACTICE MANAGEMENT

• US 20080059248A1
• Filed: 10/31/2007
• Published: 03/06/2008
• Est. Priority Date: 03/19/2001
• Status: Active Application

• Current Assignee: Jasos Intellectual Property LLC
• Original Assignee: Jasos Group, LLC
• Inventors: Moore, Terrance, Lewis, Charles
• Application Number:
  US11/933,075
• Publication Number:
  US 20080059248A1
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods, program product, and systems are provided for optimizing profits for healthcare practices and insurance networks. The methods, program product, and systems include modifying physician'"'"'s cost management behavior to enhance profitability of healthcare practices and insurance networks by identifying physicians that are not profitable because of cost management behavior and providing intervention to change the management behavior of the physician.

Claims

1. A method of managing an outpatient healthcare practice participating in an insurance network, the method comprising the steps of:

analyzing data from each of a plurality of physicians in the healthcare practice participating in the insurance network including ancillary medical costs;

identifying responsive to the analysis at least one of the plurality of physicians in the healthcare practice participating in the insurance network that is at risk of not receiving the predetermined reimbursement amount for the ancillary medical costs from the insurance network by engaging in medical procedures other than those attributed directly to a medical procedure performed by a physician and that are detrimental to receiving the predetermined reimbursement amount for the ancillary medical costs;

modifying management behavior of the at least one of the plurality of physicians at risk regarding the ancillary medical costs responsive to the identifying; and

determining that the risk of not receiving the predetermined reimbursement amount for the ancillary medical costs from the insurance network has been reduced responsive to the modifying to increase the profitability of the healthcare practice.

2. A method as defined in claim 1, wherein the step of identifying the at least one physician comprises analyzing the ancillary medical costs of each of the plurality of physicians in the healthcare practice, calculating an average ancillary medical cost per physician for the healthcare practice, and identifying the physicians that have ancillary medical costs that are a predetermined percentage greater than the average ancillary medical cost per physician for the healthcare practice.

3. A method as defined in claim 1, wherein the step of identifying the at least one physician comprises selecting the physician having the highest ancillary medical costs within the healthcare practice.

4. A method as defined in claim 3, wherein the step of modifying management behavior of the at least one physician farther comprises:

preparing a list of ancillary medical procedures that the at least one physician may engage in that enable the at least one physician to receiving the predetermined reimbursement amount for the ancillary medical costs; and

providing custom medical procedure forms that include the list of ancillary medical procedures to thereby define custom ancillary medical procedure forms and that the at least one physician should engage in to further enable the at least one physician to receive the predetermined reimbursement amount for the ancillary medical costs.

5. A method as defined in claim 1,

wherein the insurance network comprises one of the plurality of insurance networks, the at least one physician participates in the plurality of insurance networks;

and

wherein the step of modifying management behavior of the at least one physician further comprises preparing a list of common ancillary medical procedures that are approved by each of the plurality of insurance networks so as to enable the at least one physician to receive the predetermined reimbursement amount for the ancillary medical costs.

6. A method as defined in claim 5, further comprising providing patient intervention to modify the at least one physician'"'"'s management behavior, the patient intervention including identifying at least one patient whose present ancillary medical procedures put the at least one physician at risk for not receiving the predetermined reimbursements for the ancillary medical costs, amending the at least one patient'"'"'s present ancillary medical procedures to decrease the at least one physician'"'"'s risk of not receiving the predetermined reimbursements for the ancillary medical costs, and discontinuing the at least one patient'"'"'s present ancillary medical procedures that put the at least one physician at risk for not receiving the predetermined reimbursements for the ancillary medical costs.

7. A method as defined in claim 1, wherein the ancillary medical costs comprise pharmacy costs being other than those attributed by a medical procedure performed directly by any of the plurality of physicians when the respective physician directly administers a medication to a patient to thereby define ancillary pharmacy costs.

8. A method as defined in claim 7, wherein the step of modifying management behavior of the at least one physician comprises educating the at least one physician on the benefits of alternative prescription medications using research literature for comparing the alternative medications to the prescribed medications and organizing continued medical education classes to educate each of the plurality of physicians in the healthcare practice on the benefits of the alternative prescription medications.

9. A method as defined in claim 8, wherein the step of modifying management behavior of the at least one physician further comprises:

preparing a list of prescription medications that the at least one physician may prescribe that enable the at least one physician to receive the predetermined reimbursement amount for the ancillary pharmacy costs; and

providing custom prescription medication forms that include the list of prescription medications that the at least one physician may prescribe that enable the at least one physician to receive the predetermined reimbursement amount for the ancillary pharmacy costs.

10. A method as defined in claim 9, further comprising providing patient intervention to modify the at least one physician'"'"'s management behavior, the patient intervention including identifying at least one patient whose present prescription medications put the at least one physician at risk for not receiving the predetermined reimbursements for the ancillary pharmacy costs, amending the at least one patient'"'"'s present prescription medications to decrease the at least one physician'"'"'s risk of not receiving the predetermined reimbursements for the ancillary pharmacy costs, and discontinuing the at least one patient'"'"'s present prescription medications that put the at least one physician at risk for not receiving the predetermined reimbursements for the ancillary pharmacy costs.

11. A method of optimizing the profitability of an insurance network having a plurality of physicians in a healthcare practice participating therein by managing ancillary medical costs, the method comprising the steps of:

analyzing data from each of the plurality of physicians in the healthcare practice participating in the insurance network including management of medical costs other than those attributed directly to medical procedures performed by any of the plurality of physicians to thereby define ancillary medical costs;

identifying responsive to the analysis at least one of the plurality of physicians in the healthcare practice participating in the insurance network that is at risk of not receiving a predetermined reimbursement amount for the ancillary medical costs from the insurance network by performing activities that are detrimental to receiving the predetermined reimbursement amount for the ancillary medical costs;

modifying management behavior of the at least one of the plurality of physicians in the healthcare practice regarding ancillary medical costs that are not profitable for the insurance network responsive to the identifying; and

providing a financial incentive to the insurance network and the plurality of physicians in the healthcare practice participating in the insurance network to modify the plurality of physicians'"'"' management behavior of ancillary medical costs that are not as profitable to the insurance network.

12. A method as defined in claim 11, wherein the step of modifying management behavior of the at least one of the plurality of physicians further comprises providing custom medical procedure forms that include the list of the ancillary medical procedures to thereby define custom ancillary medical procedure forms and that the plurality of physicians should engage in that are more profitable to the insurance network.

13. Computer executable program product for managing a healthcare practice including a plurality of physicians and participating in an insurance network, stored on a tangible computer medium, comprising:

an analyzer in communication with at least one database for analyzing data in the at least one database and comparing ancillary medical procedures that are preferred by the insurance network with the ancillary medical costs of the plurality of physicians participating in the insurance network to thereby identify ancillary medical costs of the physicians that are not preferred by the insurance network; and

managing means responsive to the analyzer for managing the ancillary medical costs of the healthcare practice identified as not being preferred by the insurance network to thereby modify the ancillary medical costs of the physicians in the healthcare practice to be more profitable to the insurance network, the managing means including an identifier for identifying responsive to the analyzer at least one of the plurality of physicians in the healthcare practice participating in the insurance network that is at a greater risk of not receiving a predetermined reimbursement amount for the ancillary medical costs from the insurance network by engaging in ancillary medical procedures that are detrimental to receiving the predetermined reimbursement amount for the ancillary medical costs, and a modifier responsive to the identifier for modifying ancillary medical costs management behavior of the at least one of the plurality of physicians at the greater risk regarding the ancillary medical costs, the managing means further determining responsive to the modifier that the risk of not receiving the predetermined reimbursement amount for the ancillary medical costs from the insurance network has been reduced.

14. Computer executable program product as defined in claim 13, wherein the at least one database includes a first database comprising medical procedures other than those performed directly by any of the plurality of physicians to thereby define ancillary medical procedures that are preferred by the insurance network, and a second database comprising medical costs other than those attributed directly to medical procedures performed by any of the plurality of physicians to thereby define ancillary medical costs of each of the plurality of physicians participating in the insurance network.

15. Computer executable program product as defined in claim 13, wherein the analyzer further includes calculating means for calculating an average ancillary medical cost per physician for the healthcare practice and identifying the at least one physician that has ancillary medical costs that are a predetermined percentage greater than the average ancillary medical costs per physician for the healthcare practice.

16. Computer executable program product as defined in claim 15, further comprising an educator responsive to the analyzer for educating the at least one physician on benefits of alternative ancillary medical procedures using research literature for comparing the alternative ancillary medical procedures to current ancillary medical procedures.

17. Computer executable program product as defined in claim 16, wherein the managing means further comprises patient intervening means for identifying at least one patient whose present ancillary medical procedures are not preferred by the insurance network and amending the at least one patient'"'"'s present ancillary medical procedures.

18. Computer executable program product as defined in claim 17, wherein the management means further comprises generating means for generating first and second letters, the first letter informing the ancillary medical facility that the at least one patient'"'"'s ancillary medical procedures are amended to new ancillary medical procedures and the second letter informing the at least one patient that the patient'"'"'s present ancillary medical procedures are amended to the new ancillary medical procedures, wherein the first and second letters are reviewed for accuracy, signed by the physician, and transmitted to the respective ancillary medical facility and the at least one patient.

19. Computer executable program product as defined in claim 18, wherein the management means further comprises an updater for updating each of the plurality of physicians in the healthcare practice of any changes in the management of ancillary medical costs that are preferred by the insurance network.

20. Computer executable program product for managing a healthcare practice including a plurality of physicians and participating in an insurance network, stored on a tangible computer medium positioned on the server, comprising:

an updater responsive to a user interface updating each of the plurality of physicians in the healthcare practice of any changes in management of medical costs other than those attributed directly to a medical procedure performed directly by any of the plurality of physicians to thereby define ancillary medical costs and that are preferred by the insurance network;

recommending means responsive to the user interface for recommending to each of the plurality of physicians alternative medical procedures other than those performed directly by any of the plurality of physicians to thereby define ancillary medical procedures and that are preferred by the insurance network;

an analyzer in communication with at least one database and positioned to analyze data in the at least one database and compare ancillary medical procedures that are preferred by the insurance network with ancillary medical costs of the plurality of physicians participating in the insurance network to thereby identify the ancillary medical costs of the physicians that are not preferred by the insurance network; and

managing means responsive to the analyzer for managing the ancillary medical costs of the healthcare practice identified as not being preferred by the insurance network to thereby modify the ancillary medical costs of the physicians in the healthcare practice to be more profitable to the insurance network, the managing means including an identifier for identifying responsive to the analyzer at least one of the plurality of physicians in the healthcare practice participating in the insurance network that is at a greater risk of not receiving a predetermined reimbursement amount for the ancillary medical costs from the insurance network by engaging in ancillary medical procedures that are detrimental to receiving the predetermined reimbursement amount for the ancillary medical costs, and a modifier responsive to the identifier for modifying ancillary medical costs management behavior of the at least one of the plurality of physicians at the greater risk regarding the ancillary medical costs, the managing means further determining responsive to the modifier that the risk of not receiving the predetermined reimbursement amount for the ancillary medical costs from the insurance network has been reduced.

21. Computer executable program product as defined in claim 20, wherein the at least one database comprises first and second databases, the first database including the ancillary medical procedures that are more preferred by the insurance network, the second database including ancillary medical costs of each of the plurality of physicians participating in the insurance network.

22. Computer executable program product as defined in claim 20, wherein the analyzer further includes calculating means for calculating an average ancillary medical cost per physician for the healthcare practice and identifying the at least one physician that has ancillary medical costs that are a predetermined percentage greater than the average ancillary medical costs per physician for the healthcare practice.

23. Computer executable program product as defined in claim 22, farther comprising an educator responsive to the analyzer for educating the at least one physician on benefits of alternative ancillary medical procedures using research literature for comparing the alternative ancillary medical procedures to current ancillary medical procedures.

24. Computer executable program product as defined in claim 23, wherein the managing means further comprises patient intervening means for identifying at least one patient whose present ancillary medical procedures are not preferred by the insurance network and amending the at least one patient'"'"'s present ancillary medical procedures.

25. Computer executable program product as defined in claim 24, wherein the management means further comprises generating means for generating first and second letters, the first letter informing a medical facility other than that attributed directly to each of the plurality of physicians to thereby define an ancillary medical facility that the at least one patient'"'"'s ancillary medical procedures are amended to new ancillary medical procedure and the second letter informing the at least one patient that the patient'"'"'s present ancillary medical procedures are amended to the new ancillary medical procedures, wherein the first and second letters are reviewed for accuracy, signed by the physician, and transmitted to the respective ancillary medical facility and the at least one patient.