METHODS AND SYSTEMS FOR SAVING ON HEALTHCARE COSTS

• US 20090076854A1
• Filed: 09/15/2008
• Published: 03/19/2009
• Est. Priority Date: 09/13/2007
• Status: Abandoned Application

• Current Assignee: GlobalCare, Inc. (Zelis Healthcare, Inc.)
• Original Assignee: GlobalCare, Inc. (Zelis Healthcare, Inc.)
• Inventors: Bigsby, Bruce C.
• Application Number:
  US12/211,041
• Publication Number:
  US 20090076854A1
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising

Abstract

A payer may save on healthcare costs and a service provider may receive information about payment according to the inventions. Data about service providers eligible to provide services to patients at in-network rates may be made available. A user seeking a service may select a service provider from the data made available. From the network(s) in which the selected service provider participates, a matching network may be chosen. If the selected service provider participates in more than one network, access and/or savings data for each network may be used to determine the match. Other factors may determine the match. Information relating to the user and matched network is provided to the selected service provider, who or which charges in-network rates for service to the user. The payer may be charged a portion of its savings for their accomplishment.

Claims

1. A method for a payer to save on healthcare costs with respect to a user seeking healthcare service, and for a service provider to be informed about payment for the sought-after healthcare service, comprising:

making data about eligible healthcare service providers available;

receiving a request for an eligible healthcare service provider to provide healthcare service to a user;

determining a matched preferred provider organization (PPO) network for the eligible healthcare service provider from among one or more PPO networks in which the healthcare service provider participates; and

providing the healthcare service provider with information at least relating to the user and the matched PPO network, the information causing the healthcare service provider to charge for healthcare service provided to the user substantially as the service provider charges an in-network user of the matched PPO network,

whereby the payer saves on healthcare costs because the user is charged for the healthcare service as an in-network user of the matched PPO, and

whereby the healthcare service provider is informed about the payment for the healthcare service at least by reference to the provided information relating at least to the user and the matched PPO network.

2. The method of claim 1, further comprising:

verifying participation of the healthcare service provider in the matched PPO network.

3. The method of claim 1, wherein determining the matched PPO network comprises:

if the healthcare service provider participates in more than one PPO network, determining access data for each of the PPO networks;

ranking the PPO networks based on the access data determination; and

selecting a top ranked PPO network to be the matched PPO network.

4. The method of claim 3, further comprising:

after determining the access data for each of the PPO networks, normalizing the access data determination; and

ranking the PPO networks based on the normalized access data.

5. The method of claim 3, further comprising:

after ranking the PPO networks and prior to selecting the top ranked PPO network to be the matched PPO network, adjusting the ranking of the PPO networks based on one or more factors.

6. The method of claim 1, wherein determining the matched PPO network comprises:

if the healthcare service provider participates in more than one PPO network, determining savings data for each of the PPO networks;

ranking the PPO networks based on their respective savings data; and

selecting a top ranked PPO network to be the matched PPO network.

7. The method of claim 6, further comprising:

normalizing each of the savings data; and

ranking the PPO networks based on their respective normalized savings data.

8. The method of claim 1, further comprising:

providing the user with the information at least relating to the user and the matched PPO network.

9. The method of claim 1, further comprising:

billing the payer at least for a portion of what the payer saves on the healthcare costs.

10. The method of claim 1, further comprising:

requesting payment from the payer at least for providing the healthcare service provider with the information relating to the user and the matched PPO network.

11. The method of claim 1, further comprising:

paying the matched PPO network at least for referencing the matched PPO network in the information.

12. A method to obtain a favorable rate for a patient for medical care from an out-of-network medical care giver, the method comprising:

receiving an inquiry about medical care for a patient in a region which is outside a region covered by the patient'"'"'s network;

making data available about one or more medical care givers in the outside region eligible to provide the medical care at a favorable rate;

receiving identification of a medical care giver selected from the available data; and

causing the selected medical care giver to charge the favorable rate for the medical care.

13. The method of claim 12, wherein causing the selected medical care giver to charge the favorable rate comprises providing the selected medical care giver with a care notice at least identifying the patient as associated with a network in which the selected medical care giver participates.

14. The method of claim 13, wherein identifying the patient as associated with a network comprises:

determining one or more networks in which the selected medical care giver participates; and

selecting the network for associating with the patient in the care notice from the determined one or more networks in which the selected medical care giver participates.

15. The method of claim 12, further comprising:

charging a party responsible for medical care costs of the patient for obtaining the favorable rate for the medical care provided to the patient by the selected medical care giver.

16. A method of providing healthcare payment information to a healthcare provider with the information relating to a patient receiving healthcare service from the healthcare provider, comprising:

providing the healthcare provider with a service notification;

causing the service notification to identify the patient;

causing the service notification to identify a network in which the healthcare provider participates and with which the patient is associated,

whereby the identification in the service notification of the network allows the healthcare provider to determine a rate to be charged for the healthcare service to the patient.

17. The method of claim 16, further comprising:

causing the service notification to include a co-pay to be paid by the patient for the healthcare service provided by the healthcare provider.

18. Where a patient associated with a network is charged a rate for a service, a method of obtaining a comparable rate for the service provided to another patient, comprising:

identifying networks covering an area;

compiling data on the service providers providing service in the area and associated with one or more of the identified networks;

in response to a request from the other patient for a referral to a service provider selected from the data, identifying a matching network from the one or more identified networks with which the selected service provider is associated; and

instructing the selected service provider to charge a rate for a service to the other patient comparable to a rate charged to other patients associated with the matching network and receiving the service.