COMPUTER-IMPLEMENTED METHOD FOR GROUPING MEDICAL CLAIMS BASED UPON CHANGES IN PATIENT CONDITION

• US 20100324928A1
• Filed: 08/09/2010
• Published: 12/23/2010
• Est. Priority Date: 06/22/1995
• Status: Active Grant

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Inventors: Dang, Dennis K.
• Granted Patent: US 8,121,869 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

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, shifts 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.

Claims

1. A computer-implemented method for reassigning a relationship of medical claim data assigned to a first episode treatment group, comprising the step of shifting a grouping of medical claim data from a first episode treatment group to a second episode treatment group based upon occurrence of a different degree of relationship to the second episode treatment group than to the first episode treatment group.

2. The method according to claim 1, wherein the second episode treatment group is representative of medical claim data based upon at least one of a complication, co-morbidity, surgery and changed severity of the first episode treatment group.