Methods for collecting fees for healthcare management group

• US 7,941,356 B2
• Filed: 10/26/2007
• Issued: 05/10/2011
• Est. Priority Date: 03/19/2001
• Status: Active Grant

• Current Assignee: Jasos Intellectual Property LLC
• Original Assignee: Jasos Intellectual Property LLC
• Inventors: Lewis, Charles, Moore, Terrance
• Primary Examiner(s): Apple, Kirsten S
• Assistant Examiner(s): Basit, Abdul
• Application Number:
  US11/924,751
• Publication Number:
  US 20080097790A1
• Time in Patent Office: 1,292 Days
• Field of Search: 705/35, 705/2, 705/4
• US Class Current: 705/35
• CPC Class Codes: G06Q 10/04 Forecasting or optimisation specially adapted for administrative or management purposes, e.g. linear programming or "cutting stock problem" market predictions or forecasting for commercial activities G06Q30/0202
• CPC Class Codes: G06Q 10/0637 Strategic management or analysis, e.g. setting a goal or target of an organisation; Planning actions based on goals; Analysis or evaluation of effectiveness of goals
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/10 specially adapted for electronic funds transfer [EFT] systems; specially adapted for home banking systems
• 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: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

Computer implemented methods are provided for managing and optimizing the profitability of a plurality of physicians in a healthcare practice participating in an insurance network. Exemplary computer implemented methods can include, for example, comparing via one or more computers current ancillary medical procedures used by each of the plurality of physicians with one or more preferred ancillary medical procedures of the insurance network to thereby identify at least one of the plurality of physicians in the healthcare practice who engages in ancillary medical procedures that are not preferred by the insurance network. Such exemplary computer implemented methods can also include, for example, modifying the ancillary medical cost management behavior of the at least one of the plurality of physicians and distributing a predetermined percentage of savings attributed to the modified ancillary medical cost management behavior of the at least one of the plurality of physicians.

Claims

1. A computer implemented method for managing and optimizing the profitability of a plurality of physicians in a healthcare practice participating in an insurance network, the computer implemented method comprising the steps of:

receiving, via a communications network, data for each of a plurality of physicians in a healthcare practice participating in an insurance network including current ancillary medical procedures used by each of the plurality of physicians to treat one or more of a plurality of patients that obtain healthcare services from the plurality of physicians and ancillary medical costs respective to each of the plurality of physicians;

comparing, in a first computer process, the data received via the communications network for each of the plurality of physicians in the healthcare practice with one or more preferred ancillary medical procedures of the insurance network;

identifying, in a second computer process, responsive to the first computer process, at least one of the plurality of physicians in the healthcare practice who engages in ancillary medical procedures that are not preferred by the insurance network;

recommending to the at least one of the plurality of physicians in the healthcare practice, responsive to the second computer process via the communications network, alternative ancillary medical procedures that are preferred by the insurance network; and

determining, in a third computer process, whether the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice participating in the insurance network has reached the predetermined level within a preselected period of time.

2. A computer implemented method as defined in claim 1,

wherein the data received via the communications network for each of the plurality of physicians in the healthcare practice network includes at least the number of patients of each of the plurality of physicians in the healthcare practice;

and

wherein the computer implemented method further comprises the steps of;

measuring, in a fourth computer process, average ancillary medical costs of the healthcare practice on a per-member per-month basis responsive to the data received via the communications network for each of the plurality of physicians in the healthcare practice,

calculating, in the fourth computer process, a baseline per-member per-month ancillary medical costs by averaging the per-member per-month ancillary medical costs for a predetermined period of time,

subtracting, in the fourth computer process, a current month'"'"'s average per-member per-month cost from the baseline per-member per-month ancillary medical costs to thereby determine an average per-member per-month savings,

multiplying, in the fourth computer process, the average per-member per-month savings by the number of patients that obtain healthcare services from the plurality of physicians in the healthcare practice to thereby determine the savings attributed to services of the healthcare consultation group, and

distributing, in a fourth computer process, a percentage of savings attributed to services of the healthcare consultation group when the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice has decreased to the predetermined level over the preselected period of time.

3. A computer implemented method as defined in claim 1,

wherein the computer implemented method further comprises the step of calculating, in a fifth computer process, an average ancillary medical cost per physician in the healthcare practice;

and

wherein the step of comparing, in the first computer process, the data received via the communication network for each of the plurality of physicians in the healthcare practice with the one or more preferred ancillary medical procedures of the insurance network further comprises the steps of;

identifying ancillary medical procedures that have costs above the average ancillary medical cost per physician in the healthcare practice, and

identifying at least one physician having ancillary medical costs that fall a predetermined standard deviation away from the average ancillary medical cost per physician in the healthcare practice.

4. A computer implemented method as defined in claim 2 further comprising the steps of:

calculating, in a sixth computer process, a fee to be collected by the healthcare consultation group when the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice has decreased to the predetermined level during the preselected period of time;

dividing, in an seventh computer process, the savings attributed to services of the healthcare consultation group into selected percentages between at least two of the healthcare consultation group, the healthcare practice, and the insurance network; and

distributing the savings to the at least two of the healthcare consultation group, the healthcare practice, and the insurance network, based on the selected percentages.

5. A computer implemented method as defined in claim 4,

wherein ancillary medical costs include at least pharmacy costs;

and

wherein the computer implemented method further comprises the steps of;

receiving, via the communications network, pharmacy costs for each of the plurality of physicians in the healthcare practice participating in the insurance network, and

multiplying, in an eighth computer process, the savings attributed to services of the healthcare consultation group by a selected percentage to thereby determine a commission fee to be paid to the healthcare consultation.

6. A computer implemented method as defined in claim 5,

wherein the savings attributed to services of the healthcare consultation group are divided, in the seventh computer process, into selected percentages between all three of the healthcare consultation group, the healthcare practice, and the insurance network;

wherein the selected percentage of savings attributed to services of the healthcare consultation group distributed to the healthcare consultation group and the selected percentage of savings attributed to services of the healthcare consultation group distributed to the healthcare practice are both greater than the selected percentage of savings attributed to services of the healthcare consultation group distributed to the insurance network;

wherein the ancillary medical costs include one or more of pharmacy costs, radiology costs, laboratory costs, anesthesiology costs, blood costs, blood storage procedure and administration costs, electroencephalogram costs, electrocardiogram costs, IV therapy costs, organ and tissue acquisition costs, labor and delivery costs, medical and surgery supply costs, nuclear medicine costs, occupational therapy costs, physical therapy costs, speech therapy costs, therapeutic radiology costs, operating room costs, recovery room costs, emergency room costs, renal dialysis costs, respiratory therapy costs, special care costs, costs taken from federally-defined hospital departments, or other costs associated with ancillary medical procedures;

wherein the insurance network includes one or more of;

traditional insurance networks, self insured networks within companies, employers, or other large entities, or other entities that compensate the plurality of physicians in the healthcare practice participating in the insurance network a predetermined reimbursement amount for ancillary medical costs;

wherein the healthcare practice includes a plurality of physicians practicing in one or more medical fields in a particular geographical area;

wherein the preferred ancillary medical procedures include ancillary medical costs that are profitable to one of, or both;

the insurance network or the healthcare practice;

wherein the computer implemented method further comprises the step of providing, via one or more of;

mail, electronic mail through the communications network, or a personal digital assistant associated with the healthcare practice, one or more of;

a pricing structure of the healthcare consultation group, a billing structure of the healthcare consultation group, or a charging structure of the healthcare consultation group; and

wherein the step of recommending to the at least one of the plurality of physicians in the healthcare practice alternative ancillary medical procedures that are preferred by the insurance network is performed via one or more of;

mail, electronic mail through the communications network, or a personal digital assistant associated with the at least one of the plurality of physicians in the healthcare practice.

7. A computer implemented method as defined in claim 6 further comprising the steps of:

generating, in a ninth computer process, a management report detailed for each of the plurality of physicians in the healthcare practice, the management report being based on one or more of;

prescribing patterns, cost of ancillary medical cost management behavior to each of the plurality of physicians in the healthcare practice, cost of ancillary medical cost management behavior to the insurance network, peer-reviewed alternative prescription medications, and potential savings of the healthcare practice if followed;

presenting, via the communications network, the management report generated responsive to the ninth computer process to the at least one of the plurality of physicians in the healthcare practice at risk of not receiving the predetermined reimbursement amount for ancillary medical costs from the insurance network; and

providing for retrieval by the at least one physician, via the communications network, a list of ancillary medical procedures that the at least one physician may engage in that enable the at least one of the plurality of physicians in the healthcare practice to receive a predetermined reimbursement amount for ancillary medical costs from the insurance network.

8. A computer implemented method of managing a plurality of physicians in a healthcare practice participating in an insurance network comprising the steps of:

receiving, via a communications network, data for each of a plurality of physicians in a healthcare practice participating in an insurance network including current ancillary medical procedures used by each of the plurality of physicians to treat one or more of a plurality of patients that obtain healthcare services from the plurality of physicians and ancillary medical costs respective to each of the plurality of physicians;

establishing, in a first computer process, a plan to pay funds from an incentive pool selectively funded by the healthcare consultation group to the healthcare practice when ancillary medical costs of the plurality of physicians in the healthcare practice do not decrease to a predetermined level over a preselected period of time;

comparing, in a second computer process, the data received via the communications network for each of the plurality of physicians in the healthcare practice with one or more preferred ancillary medical procedures of the insurance network;

identifying, in a third computer process, responsive to the second computer process, at least one of the plurality of physicians in the healthcare practice who engages in ancillary medical procedures that are not preferred by the insurance network;

recommending to the at least one of the plurality of physicians in the healthcare practice, responsive to the third computer process via the communications network, alternative ancillary medical procedures that are preferred by the insurance network; and

determining, in a fourth computer process, whether the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice participating in the insurance network has reached the predetermined level within a preselected period of time.

9. A computer implemented method as defined in claim 8, further comprising the step of paying funds from the incentive pool selectively funded by the healthcare consultation group to the healthcare practice when the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice do not decrease to the predetermined level over the preselected period of time responsive to determining, in the fourth computer process, whether the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice participating in the insurance network has reached the predetermined level within the preselected period of time.

10. A computer implemented method as defined in claim 8,

wherein the data received via the communications network for each of the plurality of physicians in the healthcare practice network includes at least the number of patients of each of the plurality of physicians in the healthcare practice;

and

wherein the computer implemented method further comprises the steps of;

measuring, in a fifth computer process, average ancillary medical costs of the healthcare practice on a per-member per-month basis responsive to the data received via the communications network for each of the plurality of physicians in the healthcare practice,

calculating, in the fifth computer process, a baseline per-member per-month ancillary medical costs by averaging the per-member per-month ancillary medical costs for a predetermined period of time,

subtracting, in the fifth computer process, a current month'"'"'s average per-member per-month cost from the baseline per-member per-month ancillary medical costs to thereby determine an average per-member per-month savings,

multiplying, in the fifth computer process, the average per-member per-month savings by the number of patients that obtain healthcare services from the plurality of physicians in the healthcare practice to thereby determine the savings attributed to services of the healthcare consultation group, and

distributing, in a sixth computer process, a percentage of savings attributed to services of the healthcare consultation group when the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice has decreased to the predetermined level over the preselected period of time.

11. A computer implemented method as defined in claim 10,

wherein the computer implemented method further comprises the steps of:

dividing, in a seventh computer process, the savings attributed to services of the healthcare consultation group into selected percentages between at least two of the healthcare consultation group, the healthcare practice, and the insurance network,

distributing the savings to the at least two of the healthcare consultation group, the healthcare practice, and the insurance network, based on the selected percentages, and

providing at least a pricing structure of the healthcare consultation group via electronic mail through the communications network; and

wherein the step of comparing, in the first computer process, the data received via the communication network for each of the plurality of physicians in the healthcare practice with the one or more preferred ancillary medical procedures of the insurance network further comprises the steps of;

calculating an average ancillary medical cost per physician in the healthcare practice,

identifying ancillary medical procedures that have costs above the average ancillary medical cost per physician in the healthcare practice, and

identifying at least one physician having ancillary medical costs that fall a predetermined standard deviation away from the average ancillary medical cost per physician in the healthcare practice.

12. A computer implemented method as defined in claim 11,

wherein the savings attributed to services of the healthcare consultation group are divided, in the eighth computer process, into selected percentages between all three of the healthcare consultation group, the healthcare practice, and the insurance network;

wherein the selected percentage of savings attributed to services of the healthcare consultation group distributed to the healthcare consultation group and the selected percentage of savings attributed to services of the healthcare consultation group distributed to the healthcare practice are both greater than the selected percentage of savings attributed to services of the healthcare consultation group distributed to the insurance network;

wherein the step of recommending to the at least one of the plurality of physicians in the healthcare practice alternative ancillary medical procedures that are preferred by the insurance network is performed via one or more of;

mail, electronic mail through the communications network, or a personal digital assistant associated with the at least one of the plurality of physicians in the healthcare practice;

wherein the ancillary medical costs include one or more of;

pharmacy costs, radiology costs, laboratory costs, anesthesiology costs, blood costs, blood storage procedure and administration costs, electroencephalogram costs, electrocardiogram costs, IV therapy costs, organ and tissue acquisition costs, labor and delivery costs, medical and surgery supply costs, nuclear medicine costs, occupational therapy costs, physical therapy costs, speech therapy costs, therapeutic radiology costs, operating room costs, recovery room costs, emergency room costs, renal dialysis costs, respiratory therapy costs, special care costs, costs taken from federally-defined hospital departments, or other costs associated with ancillary medical procedures;

wherein the insurance network includes one or more of;

traditional insurance networks, self insured networks within companies, employers, or other large entities, or other entities that compensate the plurality of physicians in the healthcare practice participating in the insurance network a predetermined reimbursement amount for ancillary medical costs;

wherein the healthcare practice includes a plurality of physicians practicing in one or more medical fields in a particular geographical area;

wherein the preferred ancillary medical procedures include ancillary medical costs that are profitable to one of, or both;

the insurance network or the healthcare practice.