Method and system for generating statistically-based medical provider utilization profiles

• US 5,557,514 A
• Filed: 06/23/1994
• Issued: 09/17/1996
• Est. Priority Date: 06/23/1994
• Status: Expired due to Term

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Medicode Inc. (UnitedHealth Group Incorporated)
• Inventors: Seare, Jerry G., Smith-Wilson, Patricia A., Mattey, Jean A., Sennett, Vicki S., Wahlstrom, Candace C., Bentley, Matthew R., Willis, Michelle, Snyder, Eileen K., Wenzbauer, Steven J., Fredette, Rodney, VanWagoner, Kurt
• Primary Examiner(s): Hayes, Gail O.
• Assistant Examiner(s): Poinvil, Frantzy
• Application Number:
  US08/264,795
• Time in Patent Office: 817 Days
• Field of Search: 364/401, 364/406
• US Class Current: 705/2
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A method and system for analyzing historical medical provider billings to statistically establish a normative utilization profile. Comparison of a medical provider'"'"'s utilization profile with a normative profile is enabled. Based on historical treatment patterns and a fee schedule, an accurate model of the cost of a specific medical episode can be created. Various treatment patterns for a particular diagnosis can be compared by treatment cost and patient outcome to determine the most cost-effective treatment approach. It is also possible to identify those medical providers who provide treatment that does not fall within the statistically established treatment patterns or profiles.

Claims

1. A method for generating a medical provider profile using a general purpose computer system wherein said system comprising:

a central processing unit,

dynamic memory,

static memory,

a display device,

an input device,

an output device

a mass storage device which contains

a number of historical medical provider patient billing records identifiable as patient records,

a grouping of diagnosis codes,

a grouping of qualifying circumstance codes,

a grouping of staging indicators,

a grouping of preventive codes,

a grouping of complication codes,

said method comprising the steps of;

(a) selecting a diagnosis code,

(b) reading a plurality of patient records from the mass storage device into the dynamic memory, each of said patient records having said selected diagnosis code and all of said patient records read corresponding to a single patient,

(c) comparing each of said read patient records with each qualifying circumstance code in the grouping of qualifying circumstance codes,

(d) re-sorting each of said patient records having a qualifying circumstance,

(e) reading a staging indicator corresponding to said selected diagnosis code into dynamic memory, and thereby obtaining a clear window time period based on said staging indicator,

(f) creating a grouping of said selected diagnosis code with each code in the grouping of related diagnoses codes which correspond to said selected diagnosis code thereby creating a grouping of related codes,

(g) searching said plurality of read patient records for the record containing the earliest date on which said selected diagnosis code occurs and noting said date as a first occurrence date,

(h) for each read patient record corresponding to a code in said grouping of related codes, rejecting said read patient record if a comparison of each of said read patient records with said staging indicator and said first occurrence date shows that for any read patient record, the date of a read patient record predates said first occurrence date by a period of time that exceeds said clear window,

(i) for each read patient record corresponding to a code in said grouping of related codes, rejecting said read patient record if a comparison of each of said read patient record with said staging indicator and said first occurrence date shows that for any read patient record, the date of a read patient record postdates said first occurrence date by a period of time that exceeds said clear window time period,

(j) for each read patient record not rejected in steps (a) through (i) above, rejecting said record if said selected diagnosis code does not appear on at least two separate dates on said record,

(k) for each read patient record not rejected in steps (a) through (j) above, writing said record into a parameter table to create a profile for said selected diagnosis.

2. A system for establishing medical provider profiles, the system comprising:

(a) means for receiving a quantity of historical medical provider patient billing records identifiable as patient records,

(b) a grouping of diagnosis codes,

(c) a grouping of qualifying circumstances,

(d) a grouping of staging indicators,

(e) a grouping of preventive codes,

(f) a grouping of complication codes,

(g) means for selecting a diagnosis code,

(h) means for organizing a grouping of patient records, each of said organized patient records having a selected diagnosis code and all of said organized patient records corresponding to a single patient,

(i) means for comparing each of said organized patient records with each qualifying circumstance,

(j) means for rejecting each of said patient records having a qualifying circumstance,

(k) means for reading a staging indicator corresponding to said selected diagnosis code into dynamic memory, and thereby obtaining a clear window time period based on said staging indicator,

(l) means for creating a grouping of said selected diagnosis code with each code in a grouping of qualifying circumstance codes which corresponds to said selected diagnosis code thereby creating a grouping of related codes,

(m) means for searching said plurality of read patient records for the record containing the earliest date on which said selected diagnosis code occurs and noting said date as a first occurrence date,

(n) for each read patient record corresponding to a code in said grouping of related codes, means for rejecting said read patient record if a comparison of each of said read patient records with said staging indicator and said first occurrence date shows that for any read patient record, the date of a read patient record predates said first occurrence date by a period of time that exceeds said clear window time period,

(o) for each read patient record corresponding to a code in said grouping of related codes, means for rejecting said read patient record if a comparison of each of said read patient record with said staging indicator and said first occurrence date shows that for any read patient record, the date of a read patient record postdates said first occurrence date by a period of time that exceeds said clear window time period,

(p) for each read patient record not rejected in steps (a) through (o) above, means for rejecting said record if said selected diagnosis code does not appear on at least two separate dates on said record,

(q) for each read patient record not rejected in steps (a) through (p) above, means for writing said record into a parameter table to create a profile for said selected diagnosis.

3. A method for establishing a medical provider profile using a general purpose computer system wherein said computer system comprising:

a central processing unit,

dynamic memory, and

a mass storage device,

said method comprising the steps of;

(a) receiving a number of medical provider billing records,

(b) selecting a general diagnosis code,

(c) selecting a patient record that contains said diagnosis code from said medical provider billing records,

(d) comparing said patient record with a qualifying circumstance table and rejecting said patient record if it contains a qualifying circumstance code,

(e) selecting from a table containing specific diagnosis codes all specific diagnosis codes related to said general diagnosis code,

(f) selecting from a table containing preventive codes all preventive codes related to said general diagnosis code,

(g) selecting from a table containing aftermath codes all aftermath codes related to said general diagnosis code,

(h) grouping said general diagnosis code, said selected specific diagnosis codes, said selected preventive diagnosis codes, and said selected aftermath codes into a group of related codes,

(i) assigning said patient record with a staging indicator associated with a clear window time period and said general diagnosis code,

(j) determining a first occurrence of said general diagnosis code in said patient record,

(k) rejecting said patient record if a comparison of the date of each occurrence of a code in said group of related codes with said first occurrence date shows that an occurrence of a code in said group of related codes has a date that predates the first occurrence date by more than a period of time indicated by said clear window time period,

(l) rejecting said patient record if a comparison of the date of each occurrence of a code in said group of related codes with said first occurrence date shows that an occurrence of a code in said group of related codes has a date that postdates the first occurrence date by more than a period of time indicated by said clear window time period,

(m) rejecting said patient record if said diagnosis code appears in said patient record on no more than a single date,

(n) if said patient record has not been rejected, entering it into a parameter database.