COMPUTER-IMPLEMENTED METHOD FOR GROUPING MEDICAL CLAIMS INTO EPISODE TREATMENT GROUPS
First Claim
1. A computer-implemented process for profiling medical claims including the steps of:
- (a) constructing a first cluster of episode-related medical claim data, the cluster having one anchor record;
(b) grouping a second cluster of episode-related medical claim data to the first cluster of episode-related medical claim data based upon relationship of the second cluster to the medical episode represented by the first cluster; and
(c) shifting the second cluster of episode-related medical claim data to a different and distinct episode group conditioned upon a higher degree of relationship of the second cluster to the different and distinct episode group.
3 Assignments
0 Petitions
Accused Products
Abstract
A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shills groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.
61 Citations
16 Claims
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1. A computer-implemented process for profiling medical claims including the steps of:
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(a) constructing a first cluster of episode-related medical claim data, the cluster having one anchor record; (b) grouping a second cluster of episode-related medical claim data to the first cluster of episode-related medical claim data based upon relationship of the second cluster to the medical episode represented by the first cluster; and (c) shifting the second cluster of episode-related medical claim data to a different and distinct episode group conditioned upon a higher degree of relationship of the second cluster to the different and distinct episode group.
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2. A computer-implemented process for profiling medical claims including the steps of:
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(a) reading a first patient'"'"'s medical claim data, input as at least one of a plurality of data records, into a computer memory; (b) validating each of the at least one of a plurality of data records for at least one of a diagnosis code and a treatment code; (c) reading at least one pre-defined relation between the at least one of a diagnosis code and a treatment code in the validated at least one of a plurality of data records and pre-defined medical episodes; and (d) grouping the validated at least one of a plurality of data records to at least one of a plurality of episode treatment groups, each of the at least one of a plurality of episode treatment groups further comprising one anchor record and n data records linked thereto, the n data records being selected from the group consisting of ancillary records, facility records and prescription drug records, where n is an integer greater than or equal to 0, and having a predefined time window during which the n data records may group to the one anchor record. - View Dependent Claims (3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16)
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Specification