Medical reimbursement computer system

• US 4,667,292 A
• Filed: 02/16/1984
• Issued: 05/19/1987
• Est. Priority Date: 02/16/1984
• Status: Expired due to Fees

• Current Assignee: Iameter Incorporated Oakland CA
• Original Assignee: Iameter, Inc.
• Inventors: Mohlenbrock, William C., Trummell, Donald E. Jr., Kahn, Theodore E., Farley, Peter J.
• Primary Examiner(s): Smith, Jerry
• Assistant Examiner(s): Grossman, Jon D.
• Application Number:
  US06/580,799
• Time in Patent Office: 1,188 Days
• Field of Search: 364/401, 364/406, 364/407, 364/408, 364/413, 364/415, 364/464, 364/200, 364/900, 364/513, 128/904, 179/84 VF
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• 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

Abstract

A computer system for identifying the most appropriate of the billing categories (Diagnosis Related Groups) prescribed by the a governmental entity as a basis for determining the amount that health care providers, such as hospitals, are to be reimbursed under Medicare and similar programs for services provided to patients. The computer system responds to an initial determination of a category, upon admission of a patient, to list for medical personnel involved in giving care to the patient, such as the attending physician, a few other medically related categories for consideration as diagnosis and treatment proceeds. Only those related categories that can apply to a particular patient are listed for that patient, thereby reducing the time necessary for the physician to review and designate any new category that may be more accurate than the first. When a new category is designated by the attending physician, a new listing is provided the physician with those categories medically related to the newly designated category being listed. A brief review by the physician each day, with a new listing provided by the computer system for the following day'"'"'s review if the physician designates any change, gives an accurate determination of the most appropriate billing category by the time services to the patient have been completed, such as when a patient leaves a hospital. A billing category determined in a conventional manner by medical records clerical personnel after medical services are ended can then be compared and reconciled with the physician determined category in order to improve the accuracy of the conventional determination.

Claims

1. A computer based system for aiding in a determination of which one of a large number of a predetermined list of payment categories is most appropriate for reimbursement of a provider of medical services to a patient, each of said categories being dependent upon several factors including a principal diagnosis of the patient'"'"'s problem, the procedure(s) performed upon the patient, the age of the patient, and the presence or absence of any complications or co-morbidity, said system comprising:

means responsive to information of a patient for providing an attending physician soon after medical services to the patient have commenced with a listing of a plurality of payment categories that are medically related to an intial category that is determined to be correct when medical services are commenced, whereby the physician may quickly identify any such reimbursement related category that is more closely suited to the patient than the initial category, and

means responsive to an identification by the physician of one of said related categories as more closely suited to the patient than the initial category for providing the physician with a new listing of a plurality of payment categories that are medically related to the new identified category, whereby the physician has another opportunity to identify yet another reimbursement related category that is more closely suited to the patient than the identified category,

thereby aiding in an accurate payment category determination being made by the attending physician by the time medical services to the patient have ended.

2. The system according to claim 1 which additionally comprises means responsive to individual diagnosis and procedure codes determined from patient records after medical services to the patient have ended for generating therefrom a payment category and comparing that category with that determined by the attending physician, whereby an identity of categories determined by the different methods indicates an accurate single category determination and a difference between them can be the cause for a reconcillation to be made.

3. A computer system for assisting in the selection of which of a plurality of predetermined payment categories applies for medical services provided to each of a plurality of patients, comprising:

means for storing an identifying number, textual description and characteristics of each of said plurality of said predetermined payment categories, and identifying numbers of other medically related of said payment categories,

means responsive to a computer input device for receiving information of each patient,

means responsive to the payment category storage means and to the patient information receiving means for assembling a listing of a working payment category, its text and the identifying numbers and textual descriptions for each of the categories medically related to said working category, and

said patient informtion receiving means additionally comprising means including a storage medium of patient information for changing the working category in response to said input device and in a manner that said assembling means is able to reassemble a listing of the related categories for the new working category,

whereby a few categories that are possible alternatives to the working category for each of the patients are listed along with the working category, from which medical personnel may select an updated new working category and obtain a new listing of categories related to the new working category.

4. The computer system according to claim 3 which additionally comprises means responsive to the patient information receiving means and the payment category storage means for noting on said listing whether the existance of other factors would alter the working category, whereby medical personnel are altered to note the existance of any such factor.

5. The computer system according to claim 3 wherein said listing assembly means includes means for printing said listing on a single page of paper.

6. A computer system for assisting in a selection of which of a plurality of predetermined payment categories applies for medical services provided to each of a plurality of patients, comprising:

means for storing an identifying number, textual description and characteristics of each of said plurality of predetermined payment categories, such characteristics including an operative patient age range, operative patient sex, whether either a complication or co-morbidity is required for the category, and a plurality of identifying numbers of medically related categories,

means responsive to a computer input device for receiving and storing information of each patient, including the patient'"'"'s age, sex and a working payment category determination,

means responsive to the payment category storage means and to the patient information storage means for assembling a listing for each patient of the working payment category, its text and identifying numbers and textual descriptions for each of the categories related to said working category, said assembling means including means responsive to the patient storage means for eliminating those related categories that cannot exist for any of the sex, age or complications or co-morbidity of the patient, and

said patient information storage means additionally including means for changing the working category in response to said input device and in a manner that said assembling means is able to reassemble a listing of related categories for the new working category,

whereby a few categories that are possible alternatives to the working category for a particular patient are listed along with the working category, thereby making it possible for medical personnel to easily and continuously update the working category for an existing patient.

7. The computer system according to claim 6 which additionally comprises means responsive to the patient information storage means and the payment category storage means for noting on said listing whether the existance of a complication or co-morbidity would alter the working category, whereby medical personnel are alerted to note the existance of any complication or co-morbidity.

8. The computer system according to claim 6 wherein said listing assembling means includes means for printing said listing on a single page of paper.

9. The computer system according to claim 6 wherein said listing assembling means includes means responsive to the characteristics of the working payment category of said payment category storage means for including an indication in the listing as to whether the existance of a complication or comorbidity could change the working payment category to another category, whereby medical personnel are alerted as to the effect of this payment relevant factor.

10. A computer system for assisting in the selection of which of a plurality of payment categories applies for medical services provided to each of a plurality of patients, comprising:

11. means for storing an identifying number, textual description and characteristics of each of said plurality of payment categories, including the effect of a complication or comorbidity (C.C.), such characteristics comprising:

an operative patient age range,

operative patient sex,

a plurality of identifying numbers of medically related payment categories,

C.C. Move, having a first state if a C.C could make no difference in payment category assignment and a second state if a C.C. could cause selection of a different payment category, and

C.C. Age, being that age range where an existence of a C.C. makes a difference in the applicability of this payment category,

means responsive to a computer input device for receiving and storing information of each patient, including the patient'"'"'s age, sex and a working payment category determination,

means responsive to the payment category storage means and to the patient information storage means for assembling a listing for each patient of the working payment category, its text and identifying numbers and textual descriptions for at least some of the related categories,

means responsive to the payment category storage means and to the patient information storage means for including in said listing a first message if said C.C. Move of the working payment category is in its said first state and the age of the patient is within the C.C. Age,

means responsive to the payment category storage means and to the patient information storage means for including in said listing a second message if said C.C. Move of the working payment category is in its said second state and the age of the patient is within the C.C. Age, and

means responsive to the payment category storage means and to the patient information storage means for omitting both of said first and second messages when the age of the patient is not within the C.C. Age.