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

• US 6,223,164 B1
• Filed: 10/05/1995
• Issued: 04/24/2001
• Est. Priority Date: 06/23/1994
• Status: Expired due to Term

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Ingenix Incorporated (UnitedHealth Group Incorporated)
• Inventors: Wahlstrom, Candace C., Bentley, Matthew R., Mattey, Jean Andrea, Willis, Michelle, Snyder, Eileen K., Wenzbauer, Steven J., Fredette, Rodney, Smith-Wilson, Patricia A, Sennett, Vicki Sue, VanWagoner, Kurt, Seare, Jerry G
• Primary Examiner(s): Poinvil, Frantzy
• Application Number:
  US08/539,413
• Time in Patent Office: 2,028 Days
• Field of Search: 705/2, 705/3, 364/922, 707/10, 707/100
• 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,

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 clear window time periods,

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 memory, each of said patient records having at least one relevant diagnosis code and a respective date of procedure and 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) identifying each of said patient records having the proper qualifying circumstances for said selected diagnosis code,

(e) reading an indicator corresponding to an identified diagnosis into the memory, and thereby obtaining a clear window time period based on said indicator,

(f) creating a patient specific grouping of patient records, wherein each diagnosis code in said patient specific grouping of patient records corresponds to a diagnosis code in said grouping of diagnosis codes thereby creating a grouping of related patient records,

(g) from said patient records having the proper qualifying circumstances, determining a difference between dates of procedure for consecutive patient records, and if the difference is greater than or equal to said clear window time period, defining an earlier one of said two consecutive records as an ending record of an episode of care and a latter one of said two consecutive records as a beginning of an episode of care, wherein each complete episode of care has both a beginning record and an ending record,

(h) for each identified episode of care, writing said episode of care into a table to create a profile for said selected diagnosis.

4. A method as recited in claim 1 further including the step of identifying the earliest qualifying patient record as the beginning record of an initial episode of care and identifying the last qualifying patient record as the terminating record of a fmal episode of care for a patient history of records.

5. A method as recited in claim 4, wherein said initial episode of care and said final episode care are the same episode of care.

6. A method as recited in claim 4, wherein said initial episode of care and said final episode care are separate episodes of care.

7. A method as recited in claim 4 wherein said earliest qualifying patient record and said last qualifying patient record are the same patient record.

8. A method as recited in claim 4, wherein said earliest qualifying patient record and said last qualifying patient record are separate patient records.

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

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

(b) a data storage coupled to said receiver and configured to store;

a grouping of diagnosis codes,

a grouping of qualifying circumstances,

a grouping of clear window time periods,

a grouping of preventive codes, and

a grouping of complication codes,

(c) a processor coupled to said data storage arrangement and configured to provide;

means for selecting a diagnosis,

means for organizing a grouping of patient claims records, each of said organized patient claims records having at least one diagnosis code and a respective date of procedure and corresponding to a single patient,

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

means for pending each of said patient claims records if it fails to qualify,

means for reading an indicator corresponding to said selected diagnosis into memory, and thereby obtaining a clear window time period based on said indicator,

means for creating a grouping of related patient records from the patient records read from each of said organized patient claims records wherein each code in said grouping of related patient records corresponds to said selected diagnosis,

means for determining a difference between dates of procedure for consecutive patient claims records, and if the difference is greater than or equal to said clear window time period, defining the latter of said consecutive patient claims records as a beginning of an episode of care, wherein each episode of care has a beginning record and an ending record,

means for pending said record if said at least one diagnosis code corresponding to said organized patient claims record is not one of the diagnosis codes within said grouping of diagnosis codes related to said selected diagnosis,

means for writing each said valid episode of care generated into a parameter table to create a profile for said selected diagnosis.

9. A method as recited in claim 2, further including a means for identifying the earliest qualifying patient record as the beginning record of an initial episode of care and identifying the last qualifying patient record as the terminating record of a final episode of care for a patient history of records.

10. A method as recited in claim 9, wherein said initial episode of care and said final episode care are the same episode of care.

11. A method as recited in claim 9, wherein said initial episode of care and said final episode care are separate episodes of care.

12. A method as recited in claim 9, wherein said earliest qualifying patient record and said last qualifying patient record are the same patient record.

13. A method as recited in claim 9, wherein said earliest qualifying patient record and said last qualifying patient record are separate patient records.

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 patient records that contain specific diagnosis codes from said medical provider billing records,

(c) comparing each record within said patient records selected with a qualifying circumstance table and pending each said patient record compared if it fails to qualify,

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

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

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

(g) grouping said patient records selected having at least one of said selected specific diagnosis codes, said selected preventive diagnosis codes, and said selected aftercare codes into a group of related records,

(h) determining a clear window time period, said clear widow time period associated with said general diagnosis code,

(i) determining a first occurrence of one of said codes within said group of related codes,

(j) pending said patient records selected from inclusion into said group of related records if a comparison of the dates of procedure for consecutive patient records shows that the difference is greater than or equal to said clear window time period,

(k) pending each said patient record selected if each said diagnosis code within said group of related diagnosis codes fails to appear in at least one of said patient records selected,

(l) if said patient record has not been rejected, entering it into a database of episodes.

14. A method for generating with a data processing system a medical provider profile for a specific diagnosis using patient records from the medical provider, each patient record including a date of procedure and a diagnosis code, the medical provider profile having an associated clear window time period, comprising the steps of:

reading a plurality of records corresponding to a single patient, each of the records having a specific diagnosis code or a related-diagnosis code, and a respective date of procedure;

sorting the patient records by dates of procedure;

removing from further consideration each patient record that fails to satisfy a set of qualifying circumstance rules;

determining differences between dates of procedure for pairs of consecutive patient records, and if a difference for a pair is greater than or equal to the clear window time period, defining an earlier record of the pair as an ending record of an episode of care and a latter record of the pair as a beginning of an episode of care, wherein each episode of care has both a beginning record and an ending record;

generating said episode of care so that it includes a grouping of patient specific records, wherein each said specific diagnosis code associated with each record within said grouping of patient specific records has an association with a general diagnosis; and

writing remaining episodes of care into a table to create a profile for the general diagnosis associated therewith.