Web-based managed care system having a common administrative account

• US 7,742,930 B1
• Filed: 07/06/2000
• Issued: 06/22/2010
• Est. Priority Date: 07/06/2000
• Status: Expired due to Fees

• Current Assignee: NTT Data Services Corporation (Nippon Telegraph and Telephone Corporation)
• Original Assignee: Perot Systems Corporation (Dell Technologies Inc.)
• Inventors: Grous, Paul J., Abbott, Michael D., Calhoun, John C. Jr., McCormick, Mark P.
• Primary Examiner(s): Frenel; Vanel
• Application Number:
  US09/611,165
• Time in Patent Office: 3,638 Days
• Field of Search: 705/2, 705/3, 705/4, 705/30, 705/36, 709/229, 707/4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 40/12 Accounting

Abstract

A web-based system for collecting and managing administrative details of a member in a managed care organization. The system collects and makes available over the Internet to all concerned parties digital information that can be selectively retrieved, viewed and managed by all authorized participants. This information, for example, includes the personal demographic details concerning the member and their eligible dependents, their plan elections and preferences, and their benefits usage history. The aggregated information is stored in a central database, using a “member account” paradigm. The member supplies the base information for the member account at initial enrollment in a health plan, either directly through the Internet or through an interface to their employer'"'"'s human resources data system. Such information is then available to be shared via the Internet with a health provider, new employer or health insurance plan, or for the member themselves. Historical information about expenditures, usage, payments, and the like, can then be added to the record as experienced, allowing a greater ability to derive value from the contained information.

Claims

1. A computer system for use in a web-based managed care transaction system, the computer system comprising:

a memory; and

a set of linked data tables organized into a logical entity in the memory;

wherein the set of linked data tables includes for each member;

a master account table including account setup information for at least one of utilization and login actions for said web-based managed care transaction system;

a member table including identity information for at least one member and their dependents; and

a set of one or more member history tables associated with the member table, each member history table associated with a given employer plan, wherein said logical entity is persistent over changes to each member'"'"'s changes within said employer plan;

a plurality of linked tables representing a plurality of health providers, the plurality of tables including for each health provider in the plurality of health providers;

a provider information table including identity information for the health provider;

a provider specialty table identifying specialties practiced by the health provider;

a site specialty table identifying specialties practiced by the healthcare provider at one or more sites;

a hospital affiliation table identifying one or more hospitals affiliated with the health provider; and

a provider affiliation table linked to the provider information table and said employer plan, the provider information table providing an intersection of the specialties in the provider specialty table and specialties allowed by said employer plan;

wherein, for at least a given health provider from the plurality of health providers, the web-based managed care transaction system provides each member access to identity information for the given health provider, specialties practiced by the given health provider, specialties practiced by the healthcare provider at one or more sites, information related to one or more hospitals affiliated with the given health provider, and any specialties allowed by said employer plan;

wherein the web-based managed care transaction system is adapted to enable, via the linked set of data tables, an administrative account to be moved across health plans of the at least one member and their dependents throughout their life;

wherein the web-based managed care transaction system is adapted to allow the at least one member to review, manage, and update the administrative account via a web browser, the administrative account comprising a history of health plans including past and present health plans of the at least one member and their dependents;

wherein the administrative account is owned by the at least one member;

wherein the web-based managed care transaction system provides a personal healthcare network for each member, the personal healthcare network comprising the member, at least one employer, and at least one health provider;

wherein the personal healthcare network facilitates secure communication of healthcare-related information therethrough; and

wherein the web-based managed care transaction system limits communication of the member'"'"'s healthcare-related information to selected parties of the personal healthcare network of the member.

2. The computer system as described in claim 1 wherein the set of data tables includes an employer table having associated therewith a set of one or more employer plan tables.

3. The computer system as described in claim 2 wherein a given employer plan table identifies a given employer plan.

4. The computer system as described in claim 2 further including a managed care organization (MCO) table having associated therewith a set of one or more MCO product plan tables.

5. The computer system as described in claim 4 wherein a given MCO product plan table has associated therewith the set of one or more employer plan tables.

6. The computer system as described in claim 1 wherein a given member history table has associated therewith a set of one or more coordinated benefits tables.

7. The computer system as described in claim 1 wherein a given member history table has associated therewith a set of one or more assigned primary care physician (PCP) tables.

8. The computer system as described in claim 7 wherein an assigned PCP table has associated therewith a given provider affiliation table.

9. The computer system as described in claim 1 wherein the provider information table includes a set of one or more provider staff tables.

10. The computer system as described in claim 1 wherein the set of data tables includes a staging area table that includes data which tracks the member through various transaction events.

11. A web-based managed care transaction system accessible over a computer network using a client browser, comprising:

a transaction server;

a database for storing a set of linked data tables organized into a persistent logical entity wherein said logical entity maintains data on each member in spite of status changes;

wherein the set of linked data tables includes for each member;

a master account table including account setup information for at least one of utilization and login actions for said web-based managed care transaction system;

a member table including identity information for at least one member and their dependents; and

a set of one or more member history tables associated with the member table, each member history table associated with a given employer plan;

a plurality of linked tables representing a plurality of health providers, the plurality of tables including for each health provider in the plurality of health providers;

a provider information table including identity information for the health provider;

a provider specialty table identifying specialties practiced by the health provider;

a site specialty table identifying specialties practiced by the healthcare provider at one or more sites;

a hospital affiliation table identifying one or more hospitals affiliated with the health provider; and

a provider affiliation table linked to the provider information table and said employer plan, the provider information table providing an intersection of the specialties in the provider specialty table and specialties allowed by said employer plan;

wherein the web-based managed care transaction system is adapted to enable, via the linked set of data tables, an administrative account to be moved across health plans of the at least one member and their dependents throughout their life;

wherein the web-based managed care transaction system is adapted to allow the at least one member to review, manage, and update the administrative account via the client browser, the administrative account comprising a history of health plans including past and present health plans of the at least one member and their dependents;

wherein the administrative account is owned by the at least one member;

wherein the web-based managed care transaction system provides a personal healthcare network for each member, the personal healthcare network comprising the member, at least one employer, and at least one health provider;

wherein the personal healthcare network facilitates secure communication of healthcare-related information therethrough; and

wherein the web-based managed care transaction system limits communication of the member'"'"'s healthcare-related information to selected parties of the personal healthcare network of the member.

12. A network-based managed care system comprising a network based server;

at least one client machine on which a graphical user interface operates;

a network based subsystem comprising;

a multiplexer;

a plurality of functional modules;

a transaction processor; and

a database wherein a logical entity retains data representative of users received healthcare within said database persistent across changes to a user'"'"'s healthcare plan

wherein the database includes;

a master account table for retaining account setup information for at least one of utilization and login actions for said network-based managed care system; and

a member table including identity information for at least one member and their dependents;

a plurality of linked tables representing a plurality of health providers, the plurality of tables including for each health provider in the plurality of health providers;

a provider information table including identity information for the health provider;

a provider specialty table identifying specialties practiced by the health provider;

a site specialty table identifying specialties practiced by the healthcare provider at one or more sites;

a hospital affiliation table identifying one or more hospitals affiliated with the health provider; and

a provider affiliation table linked to the provider information table and said employer plan, the provider information table providing an intersection of the specialties in the provider specialty table and specialties allowed by said employer plan;

a managed care organization (MCO) subsystem interfaced to said transaction processor;

wherein the network-based managed care system is adapted to enable, via the database, an administrative account to be moved across health plans of the at least one member and their dependents throughout their life;

wherein the administrative account comprises a history of health plans including past and present health plans of the at least one member and their dependents;

wherein the administrative account is owned by the at least one member; and

wherein the network-based managed care transaction system provides a personal healthcare network for each member, the personal healthcare network comprising the member, at least one employer, and at least one health provider;

wherein the personal healthcare network facilitates secure communication of healthcare-related information therethrough; and

wherein the network-based managed care system limits communication of the member'"'"'s healthcare-related information to selected parties of the personal healthcare network of the member.

13. The network-based managed care system of claim 12 wherein said functional modules comprise:

an enrollment module;

billing module;

messaging module; and

inquiry module.

14. The network-based managed care system of claim 12, wherein changes to a user'"'"'s health plan occur as a user changes employment.

15. The network-based managed care system of claim 12, wherein changes to a user'"'"'s health plan occur as a user changes their healthcare plan.

16. The network-based managed care system of claim 12 wherein the network comprises an Internet.

17. The network-based care system of claim 12 wherein said database contains a historical record of care provided to said user.

18. The network-based managed care system of claim 12 wherein said persistent logical entity comprises the administrative account.

19. The network-based managed care system of claim 18 wherein said persistent logical entity spans a user'"'"'s change in employment plans.