Systems and methods for pharmacy claims-based condition identification proxies

• US 7,720,697 B1
• Filed: 08/28/2008
• Issued: 05/18/2010
• Est. Priority Date: 08/28/2008
• Status: Active Grant

• Current Assignee: Change Healthcare Holdings, LLC (UnitedHealth Group Incorporated)
• Original Assignee: Mckesson Financial Holdings Limited (McKesson Corp.)
• Inventors: Silverstein, Steven Richard
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): NGUYEN, TRANG T
• Application Number:
  US12/200,441
• Time in Patent Office: 628 Days
• Field of Search: 705/2, 705/3
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients

Abstract

Systems and methods may be provided for pharmacy claims-based condition identification proxies. The systems and methods may include receiving, by a condition identification system, at least one pharmacy claim associated with a patient, where each pharmacy claim is associated with a medication previously filled by the patient, and identifying, by the condition identification system, the patient as a candidate for at least one chronic medical condition by analyzing the at least one pharmacy claim associated with the patient. The systems and methods may also include determining, by the condition identification system, a pharmacy home for the patient, and transmitting, by the condition identification system to a pharmacy computer associated with the pharmacy home, an identification of the patient that is the candidate for at least one chronic medical condition, where the patient is offered at least one service by the pharmacy home based upon the transmitted identification of the patient.

Claims

1. A computer-implemented method, comprising:

receiving, by a condition identification system comprising one or more computers, at least one pharmacy claim associated with a patient, wherein each pharmacy claim is associated with a medication previously filled by the patient;

identifying, by the condition identification system, the patient as a candidate for at least one chronic medical condition by analyzing the at least one pharmacy claim associated with the patient;

determining, by the condition identification system, a pharmacy home for the patient based upon a history of prior pharmacy claims associated with the patient, wherein the pharmacy home is determined by selecting the pharmacy location that is designated by a majority of the prior pharmacy claims associated with the patient; and

transmitting, by the condition identification system to a pharmacy computer associated with the pharmacy home, an identification of the patient that is the candidate for at least one chronic medical condition, wherein the patient is offered at least one service by the pharmacy home based upon the transmitted identification of the patient.

2. The computer-implemented method of claim 1, wherein the condition identification system receives a plurality of pharmacy claims for a plurality of patients, including the at least one pharmacy claim associated with the patient.

3. The computer-implemented method of claim 2, wherein the plurality of claims is received in a pharmacy claims file associated with a payor computer, wherein the plurality of claims have been previously adjudicated by the payor computer.

4. The computer-implemented method of claim 1, wherein, the at least one pharmacy claim associated with the patient comprises a plurality of pharmacy claims associated with the patient, wherein at least one of the plurality of pharmacy claims is associated with a first medication.

5. The computer-implemented method of claim 4, wherein the condition identification system identifies the patient as the candidate for at least one chronic medical condition at least in part by determining that the first medication is associated with a treatment for a first chronic medical condition.

6. The computer-implemented method of claim 5, wherein the condition identification system identifies the patient as the candidate for at least one chronic medical condition by further determining that a total number of the plurality of pharmacy claims associated with the patient within a time frame exceeds a threshold number.

7. The computer-implemented method of claim 5, wherein at least one of the plurality of pharmacy claims is associated with a second medication different from the first medication, wherein the condition identification system identifies the patient as the candidate for at least one chronic medical condition by further determining that the second medication is associated with a treatment for a second chronic medical condition different from the first chronic medical condition.

8. The computer-implemented method of claim 1, wherein the pharmacy home offers the patient medication therapy management (MTM) services based upon the transmitted identification of the patient to the pharmacy computer.

9. The computer-implemented method of claim 1, wherein if no pharmacy location is designated by a majority of the prior pharmacy claims associated with the patient, then the condition identification system determines the pharmacy home for the patient by selecting, based upon the prior pharmacy claims, the pharmacy location where the patient has spent the most amount of money.

10. A system, comprising:

a memory for storing computer-executable instructions;

a processor configured to access the memory and to execute the computer-executable instructions to;

receive, from a payor computer, at least one pharmacy claim associated with a patient, wherein each pharmacy claim is associated with a medication previously filled by the patient,

identify, based upon an analysis of the at least one pharmacy claim, the patient as a candidate for at least one chronic medical condition,

determine a pharmacy home for the patient based upon a history of prior pharmacy claims associated with the patient, wherein the pharmacy home is determined by selecting the pharmacy location that is designated by a majority of the prior pharmacy claims associated with the patient, and

transmit, to a pharmacy computer associated with the pharmacy home, an identification of the patient that is the candidate for at least one chronic medical condition, wherein the patient is offered at least one service by the pharmacy home based upon the transmitted identification of the patient.

11. The system of claim 10, wherein the processor is configured to receive a plurality of pharmacy claims for a plurality of patients, including the at least one pharmacy claim associated with the patient.

12. The system of claim 11, wherein the plurality of claims is received in a pharmacy claims file, wherein the plurality of claims have been previously adjudicated by the payor computer.

13. The system of claim 10, wherein the at least one pharmacy claim associated with the patient comprises a plurality of pharmacy claims associated with the patient, and wherein at least one of the plurality of pharmacy claims is associated with a first medication.

14. The system of claim 13, wherein the processor is configured to identify the patient as the candidate for at least one chronic medical condition at least in part by determining that the first medication is associated with a treatment for a first chronic medical condition.

15. The system of claim 14, wherein the processor is configured to identify the patient as the candidate for at least one chronic medical condition by further determining that a total number of the plurality of pharmacy claims associated with the patient within a time frame exceeds a threshold number.

16. The system of claim 14, wherein at least one of the plurality of pharmacy claims is associated with a second medication different from the first medication, wherein the processor is configured to identify the patient as the candidate for at least one chronic medical condition by further determining that the second medication is associated with a treatment for a second chronic medical condition different from the first chronic medical condition.

17. The system of claim 10, wherein the pharmacy home offers the patient medication therapy management (MTM) services based upon the transmitted identification of the patient to the pharmacy computer.

18. The system of claim 10, wherein if no pharmacy location is designated by a majority of the prior pharmacy claims associated with the patient, then the processor is configured to determine the pharmacy home for the patient by selecting, based upon the prior pharmacy claims, the pharmacy location where the patient has spent the most amount of money.