Cluster of correlated medical claims in an episode treatment group

• US 7,725,333 B2
• Filed: 06/12/2007
• Issued: 05/25/2010
• Est. Priority Date: 06/22/1995
• Status: Expired due to Fees

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Ingenix Incorporated (UnitedHealth Group Incorporated)
• Inventors: Dang, Dennis K.
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): LE, LINH GIANG
• Application Number:
  US11/761,855
• Publication Number:
  US 20080097788A1
• Time in Patent Office: 1,078 Days
• Field of Search: 705 2- 4, 600/300
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• 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
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

Claims

1. A computer-implemented method for storing a cluster of medical claim data representing correlated medical services rendered to a patient by one or more healthcare providers, comprising:

storing in an electronic database an episode treatment group comprising a plurality of medical claim data records representing correlated medical services rendered to a patient by one or more healthcare providers for treatment of a selected disease or health condition, wherein each medical claim data record has an associated date of service;

storing in the electronic database an episode treatment group classification and a unique episode treatment group identifier for the episode treatment group; and

storing in the electronic database an associated dynamic time window for the episode treatment group, wherein the associated dynamic time window defines a time period during which medical claim data records may be clustered into the episode treatment group, and wherein the time window for the episode treatment group is dynamically adjusted by a computer processor until no correlated medical services are detected within the defined time period after the latest associated date of service of the medical claim data records in the episode treatment group.

2. The method recited in claim 1, wherein the episode treatment classification for the stored episode treatment group is shifted to a second episode treatment group classification when one or more additional medical claim data records of the patient are added to the stored episode treatment group that indicate a change in the patient'"'"'s condition.

3. The method recited in claim 1, wherein the episode treatment group comprises at least one ancillary record and at least one anchor record.

4. The method recited in claim 1, wherein the episode treatment group classification is assigned to the stored episode treatment group based upon the patient'"'"'s age, complicating conditions, comorbidities or major surgeries.

5. The method recited in claim 1, wherein the episode treatment classification for the stored episode treatment group is shifted to a second episode treatment group classification when one or more additional medical claim data records of the patient are added to the stored episode treatment group that indicate a change in the patient'"'"'s condition based upon a comorbidity, complication or defining surgery.

6. The method recited in claim 1, wherein the stored episode treatment group includes pharmaceutical claim data for the patient.

7. The method recited in claim 1, further comprising storing an assigned primary care physician for the episode treatment group.