Computerized system and methods for adjudicating and reimbursing for healthcare services based on quality

• US 7,801,744 B2
• Filed: 01/06/2006
• Issued: 09/21/2010
• Est. Priority Date: 01/06/2005
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Patterson, Neal L.
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): Pauls; John A
• Application Number:
  US11/327,223
• Publication Number:
  US 20060265251A1
• Time in Patent Office: 1,719 Days
• Field of Search: 704/2, 704/4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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 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 for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate. The method further includes the steps of accessing a second knowledge base containing at least one criterion for assessing quality of care and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine if the care provided is medically appropriate. Also, the method includes determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.

Claims

1. One or more tangible computer-storage media having computer-useable instructions embodied thereon for performing a method for adjudicating and reimbursing a care provider for services provided for a clinical event, the method comprising:

receiving a transaction including a number of clinical event details for the clinical event;

determining an initial level of reimbursement using the number of clinical event details for the clinical event;

accessing a first knowledge base comprising a number of criteria for assessing quality of health care provided for the clinical event;

selecting at least one appropriate criterion based on the clinical event details;

wherein the criteria comprises mortality, morbidity, length of visit or stay in a healthcare facility, onset of another condition due to poor care, recurrence, elimination of presenting problem, quality of life indicators, patient satisfaction and unplanned visits due to poor care;

performing analysis of the clinical event details against the selected at least one criterion to determine the quality of health care;

determining, via a computing device, a quality adjustment for use in adjusting the initial level of reimbursement in accordance with the quality of health care provided for the clinical event using the clinical event details electronically documented by the care provider at a point of care for the clinical event for which reimbursement is sought; and

determining an adjusted level of reimbursement by applying the quality adjustment to the initial level of reimbursement to attain the adjusted level of reimbursement.

2. The media according to claim 1, further comprising accessing the electronic health record data store including electronic health record (EHR) data elements.

3. The media according to claim 2, wherein the step of selecting at least one appropriate criteria is further based on EHR data elements.

4. The media according to claim 1, further comprising accessing a data store including a number of pre-existing transactions.

5. The media according to claim 4, further comprising selecting a number of pre-existing transactions based on the clinical event details.

6. The media according to claim 5, wherein the step of determining the quality of care and level of reimbursement based on the selected preexisting transactions.

7. The media according to claim 1, further comprising accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer.

8. The media according to claim 1, further comprising accessing a second knowledge base comprising evidence-based options for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one option from the second knowledge base to determine if the care provided is medically appropriate.

9. The media according to claim 1, further comprising authorizing reimbursement of the care provider from the at least one payer.

10. The media according to claim 1, further comprising reimbursing the provider in real-time.

11. The media according to claim 1, wherein the clinical event details are documented as part of the provision of care.

12. One or more tangible computer-storage media having computer-useable instructions embodied thereon for performing a method for adjudicating and reimbursing a care provider for services provided for a clinical event, the method comprising:

receiving a transaction including a number of clinical event details for the clinical event corresponding with a patient that have been electronically documented by a care provider at a point of care for the clinical event for which reimbursement is sought;

identifying an initial level of reimbursement for the clinical event based on medical appropriateness of health care provided to the patient as indicated by a comparison of the clinical event details of the clinical event to one or more guidelines or standards of care;

accessing a first knowledge base comprising a number of criteria for assessing quality of health care provided for the clinical event, wherein each of the number of criteria comprises a measurable or observable condition indicating relative success of health care provided for the clinical event corresponding with the patient;

wherein the criteria comprises mortality, morbidity, length of visit or stay in a healthcare facility, onset of another condition due to poor care, recurrence, elimination of presenting problem, quality of life indicators, patient satisfaction and unplanned visits due to poor care;

selecting at least one appropriate criterion based on the clinical event details;

determining that a clinical condition indicated within an electronic health record (EHR) data element for the patient affects a relevant measurement of one of the at least one appropriate criterion;

adjusting the one of the at least one appropriate criterion in accordance with the EHR data element;

performing analysis of the clinical event details against the selected at least one criterion to determine the quality of health care provided for the clinical event; and

determining, via a computing device, a reimbursement adjustment based on the quality of health care provided for the clinical event using electronic health record (EHR) data elements associated with the patient from an electronic health record data store of a central computing system having historical electronic health record data elements received from a plurality of sources and using the clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought; and

applying the reimbursement adjustment, based on the quality of care provided to the patient, to the initial level of reimbursement, based on the medical appropriateness of health care provided to the patient, to determine an adjusted level of reimbursement.

13. One or more tangible computer-storage media having computer-useable instructions embodied thereon for performing a method for adjudicating and reimbursing a care provider for services provided for a clinical event, the method comprising:

receiving a transaction including a number of clinical event details for the clinical event;

determining an initial level of reimbursement using the number of clinical event details for the clinical event;

reimbursing the care provider in accordance with the initial level of reimbursement for the services provided to a patient for the clinical event;

receiving one or more clinical data elements associated with a condition that occurs after the care provider is reimbursed;

accessing a first knowledge base comprising a number of criteria for assessing quality of health care provided to the patient;

wherein the criteria comprises mortality, morbidity, length of visit or stay in a healthcare facility, onset of another condition due to poor care, recurrence, elimination of presenting problem, quality of life indicators, patient satisfaction and unplanned visits due to poor care;

selecting at least one appropriate criterion based on the clinical event details and the one or more clinical data elements;

performing analysis of the clinical event details and the one or more clinical data elements against the selected at least one criterion to determine the quality of health care provided to the patient;

determining, via a computing device, a quality adjustment for use in adjusting the initial level of reimbursement in accordance with the quality of health care provided to the patient; and

applying the quality adjustment to an account of the care provider by debiting or crediting the account to result in an adjusted level of reimbursement provided to the care provider for services provided to the patient.