METHOD FOR HIGH-RISK MEMBER IDENTIFICATION
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Abstract
A method for using claims data to identify high-risk members of a healthcare plan is disclosed. In one embodiment, the present invention includes searching the plurality of claims of members selected by a filtering criteria to identify the presence of an intervention flag, to identify factors influencing care intervention, and identifying a medical episode driving the member'"'"'s cost. In one embodiment, the intervention flag the medical episode are displayed in association with an identification of the member. In another embodiment, the member selection criteria includes selection based on the member'"'"'s predicted future health care utilization.
42 Citations
36 Claims
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1-30. -30. (canceled)
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31. A computer-implemented high risk member identification method, comprising a computer performing the following:
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identifying a group of members to be analyzed using a computer software application, each group member having an associated relative risk value, wherein the relative risk value for each member is a function of predicted future healthcare resource utilization for the member; filtering the group members using the computer software application to identify members having an associated relative risk value that exceeds a threshold value of relative risk, thereby identifying a subset of the group members for potential intervention; analyzing healthcare claim data associated with each subset member using the computer software application to ascertain the presence or absence of each of a plurality of intervenability factors present to the subset member, wherein the intervenability factors for each subset member are identified based upon aspects of each subset member'"'"'s healthcare history that are amenable to intervention by an intervention agent; using the computer software application to assign each subset member a number of intervenability factors representing a total number of the intervenability factors present in the subset member'"'"'s healthcare claim data; using the computer software application to assign a relative risk ranking to each subset member based upon the subset member'"'"'s associated relative risk value and the number of intervenability factors assigned to the subset member; and displaying (a) a list of the subset members ordered by respective relative risk rankings and (b) the relative risk value for each subset member on an electronic display. - View Dependent Claims (32, 33, 34, 35, 36)
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Specification