Medical claims integration and data analysis system
First Claim
1. A system for integrating medical claim/encounter records for comparative analysis, the system comprising:
- A) data storage means for storing medical claims data from one or more data sources, the medical claims data comprising medical claim items, at least a first portion of the medical claim items comprising principal diagnosis codes, and at least a second portion of the medical claim items comprising non-principal diagnosis codes, no diagnosis codes, or incorrect diagnosis codes; and
B) data processing means comprisingi) means for forming patient treatment episodes (PTEs) from the principal diagnosis codes, each PTE being of a diagnostic cluster type; and
ii) means for assigning at least some of the claim items of the second portion of the medical claims to the PTEs on the basis of a relationship between the second portion claim items and the PTEs.
1 Assignment
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Accused Products
Abstract
A medical claims analysis system and method categorizes medical claims into episodes of care having predetermined diagnostic cluster types. The system analyzes medical claim items, some of which have principal diagnosis codes, and some of which have non-principal, missing, or incorrect diagnosis codes. Patient treatment episodes (PTEs) are formed from the principal diagnosis codes, each PTE being of a particular diagnostic cluster type. The system categorizes non-principal-diagnosis claim items into the PTEs on the basis of temporal, physiological or clinical relationships between the claim items and the PTEs. A drug lookup table enables drug claims to be properly categorized in the PTEs. A diagnostic cluster lookup table enables claim items to be categorized into PTEs with ongoing treatment windows for which the diagnosis code of the claim item is in the diagnostic cluster lookup table. The system merges PTEs of the same diagnostic cluster type when the treatment windows of the PTEs overlap. The system attempts to recategorize medical claims into merged PTEs. The system analyzes each PTE to determine the presence of required diagnoses and eliminates any PTE without a required diagnosis. The system also identifies and merges PTEs that are clinically related or clinically similar. In a system for integrating medical claims data, medical claim items that are in different data formats and/or use different coding systems are analyzed, and related claim items are categorized in a common coding system.
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Citations
41 Claims
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1. A system for integrating medical claim/encounter records for comparative analysis, the system comprising:
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A) data storage means for storing medical claims data from one or more data sources, the medical claims data comprising medical claim items, at least a first portion of the medical claim items comprising principal diagnosis codes, and at least a second portion of the medical claim items comprising non-principal diagnosis codes, no diagnosis codes, or incorrect diagnosis codes; and B) data processing means comprising i) means for forming patient treatment episodes (PTEs) from the principal diagnosis codes, each PTE being of a diagnostic cluster type; and ii) means for assigning at least some of the claim items of the second portion of the medical claims to the PTEs on the basis of a relationship between the second portion claim items and the PTEs. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22)
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23. A method of integrating medical claim/encounter records for comparative analysis, the method comprising the steps of:
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A) storing medical claims data from one or more data sources, the medical claims data comprising medical claim items, at least a first portion of the medical claim items comprising principal diagnosis codes, and at least a second portion of the medical claim items comprising non-principal diagnosis codes, no diagnosis codes, or incorrect diagnosis codes; B) forming patient treatment episodes (PTEs) from the principal diagnosis codes, each PTE being of a diagnostic cluster type; and C) assigning at least some of the claim items of the second portion of the medical claims to the PTEs on the basis of a relationship between the second portion claim items and the PTEs. - View Dependent Claims (24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39)
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40. A system for integrating medical claim/encounter records which comprises:
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A) data storage means for storing medical claims data, the medical claims data comprising medical claim items, each claim item having an associated treatment date, a first portion of the medical claim items comprising principal diagnosis codes; B) means for forming initial patient treatment episodes (PTEs) from the principal diagnosis codes, each PTE comprising a predetermined treatment window extending from a last treatment in the PTE; C) means for assigning at least some of a second portion of the claim items into respective PTEs on the basis of a temporal overlap between the second portion claim items and the treatment windows of the PTEs and extending the treatment window for each respective PTE from the date of treatment of the second portion claim item assigned thereto provided that such date of treatment is later than the prior last treatment in the PTE; and D) means for reanalyzing at least some of the second portion claim items and assigning such claim items to respective PTEs on the basis of a temporal overlap between the second portion claim items and the extended treatment windows of the PTEs.
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41. A system for assigning medical claims to a physician which comprises:
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A) data storage means for storing medical claims data, the medical claims data comprising medical claim items for treatment of a condition by the physician, and other medical claim items related to treatment of the condition, each medical claim item having a charge; B) means for forming patient treatment episodes (PTEs) from the medical claim items, a PTE for the condition including claim items for treatment by the physician and other claim items related to treatment of the condition; C) means for determining whether the charges by the physician in the PTE for the condition exceed a predetermined threshold; and D) means for assigning all of the charges in the PTE for the condition to the physician in the event that the charges by the physician in the PTE for treatment of the condition exceed the predetermined threshold.
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Specification