Computerized system and methods for adjudicating and automatically reimbursing care providers

• US 7,881,950 B2
• Filed: 01/06/2006
• Issued: 02/01/2011
• 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): Gilligan; Luke
• Assistant Examiner(s): Molina; Anita
• Application Number:
  US11/327,055
• Publication Number:
  US 20060265250A1
• Time in Patent Office: 1,852 Days
• Field of Search: 705 2- 4
• US Class Current: 705/3
• 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 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 computer-storage media having computer-useable instructions embodied thereon for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:

receiving, at a central computing system from a remote computer, a transaction from a care provider, the transaction including one or more clinical event details stored within a data store of the care provider that have been electronically documented by the care provider at a point of care for the clinical event for which reimbursement is sought;

aggregating, at the central computing system, electronic medical record data elements from an electronic medical record data store of the central computing system with the corresponding one or more clinical event details electronically documented by the care provider at the point of care, wherein the electronic medical record data store includes historical electronic medical record data elements received from a plurality of providers;

accessing payer information for one or more payers;

determining a reimbursement amount for a first payer directly using the electronic medical record data elements from the electronic medical record data store of the central computing system having historical electronic medical record data elements received from the plurality of providers and using the corresponding one or more clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought, wherein determining the reimbursement amount comprises

(1) accessing a first knowledge base including appropriateness criteria for the clinical event for which reimbursement is sought, wherein appropriateness criteria comprises one or more guidelines, standards, or a combination thereof,

(2) determining the medical appropriateness of the clinical event by comparing at least a portion of the one or more clinical event details of the transaction to the appropriateness criteria for that clinical event,

(3) determining an initial reimbursement amount for the first payer based on the determined medical appropriateness,

(4) accessing a second knowledge base including criteria for assessing quality of care, wherein quality of care criteria comprises one or more of a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care,

(5) determining that at least one of the electronic medical record data elements affects at least one of the criteria for assessing quality of care, and, in response thereto, adjusting the at least one of the criteria for assessing quality of care,

(6) determining the quality of care by comparing the adjusted at least one criteria against at least a portion of the one or more clinical data elements of the transaction and the electronic medical record data elements from the electronic medical record data store of the central computing system having historical electronic medical record data elements received from the plurality of providers, and

(7) determining an adjusted reimbursement amount for the first payer, the adjusted reimbursement amount being adjusted from the initial reimbursement amount based on the determined quality of care provided; and

automatically initiating reimbursement of the care provider by the first payer in accordance with the adjusted reimbursement amount.

2. The media of claim 1, further comprising:

determining a reimbursement amount based on the clinical event detail for a second payer.

3. The media of claim 2, wherein the second payer is a consumer.

4. The media of claim 3, wherein the reimbursement from the second payer is from a health savings account.

5. The media of claim 1, further comprising the step of determining whether the transaction is eligible for reimbursement by the first payer.

6. The media of claim 1, further comprising reimbursing the provider in real-time.

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

receiving, at a central computing system, one or more transactions from one or more providers via one or more remote computers, each transaction including one or more clinical event details stored within a data store of the corresponding provider that have been electronically documented a care provider for the clinical event for which reimbursement is sought;

accessing payer information for one or more payers;

for each transaction, determining a quality of care provided to a patient in association with the transaction by comparing the one or more clinical event details of the transaction electronically documented by the care provider for the clinical event and one or more electronic medical record data elements from an electronic medical record data store having historical electronic medical record data elements received from a plurality of providers to one or more quality criteria stored within a knowledge base including criteria for assessing quality of care, wherein the one or more quality of care criteria comprise a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care;

for each transaction, determining a reimbursement amount from a first payer and a second payer based on the clinical event details electronically documented and the determined quality of care provided; and

for each transaction, automatically initiating reimbursement of the care provider by the first payer and the second payer.

8. The media of claim 7, wherein the second payer is a consumer.

9. The media of claim 8, wherein the reimbursement from the second payer is from a health savings account.

10. The media of claim 7, the step of determining a reimbursement amount further comprises accessing a first knowledge base including at least one option for providing medically appropriate care, and selectively performing analysis of the clinical data elements of the transaction against the at least one option to determine if the care provided is medically appropriate.

11. The media of claim 10, wherein the clinical options consist of guidelines and standards.

12. The media of claim 7, further comprising the step of determining whether the transaction is eligible for reimbursement by the first payer.

13. The media of claim 7, further comprising reimbursing the provider in real-time.

14. A medical information computing system embodied on one or more computer-storage media having computer-useable instructions embodied thereon for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising:

an initial transaction aggregator for receiving and aggregating a transaction from one or more providers, each transaction using one or more clinical event details stored within a data store of the corresponding provider that have been electronically documented by a care provider for the clinical event for which reimbursement is sought and for generating an integrated transaction including clinical data elements comprising the clinical event details and electronic medical record data elements from an electronic medical record data store having historical electronic medical record data elements received from a plurality of providers;

a data store for storing the clinical event details electronically documented in an electronic medical record by the care provider for the clinical event for which reimbursement is sought;

an appropriateness module for determining if care provided by the care provider is medically appropriate based on a comparison of the clinical data elements against appropriateness criteria, wherein appropriateness criteria comprises one or more guidelines and standards;

a reimbursement level module for determining an initial level of reimbursement from a first payer and a second payer based on the clinical data elements stored in the clinical data store and the appropriateness determination;

a quality module for determining a quality of care provided to a patient by the care provider based on a comparison of the clinical data elements against one or more quality criteria stored within a knowledge base including criteria for assessing quality of care, wherein the one or more quality criteria comprise one or more of a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care;

an adjustment module for adjusting the initial level of reimbursement from a first payer and a second payer based on the determined quality of care provided to the patient by the care provider to attain an adjusted level of reimbursement to be provided to the care provider; and

a reimbursement module for automatically reimbursing the care provider by the first payer and the second payer in real time.

15. The system of claim 14, further comprising an eligibility module for determining whether the transaction is eligible for reimbursement by the first payer.

16. The system of claim 14, wherein the second payer is a consumer.