Computer implemented methods to manage the profitability of an insurance network

• US 7,974,900 B2
• Filed: 01/06/2010
• Issued: 07/05/2011
• Est. Priority Date: 03/19/2001
• Status: Expired due to Fees

• Current Assignee: Jasos Intellectual Property LLC
• Original Assignee: Jasos Intellectual Property LLC
• Inventors: Lewis, Charles, Moore, Terrance
• Primary Examiner(s): Abdi, Kambiz
• Assistant Examiner(s): Basit, Abdul
• Application Number:
  US12/683,252
• Publication Number:
  US 20100174561A1
• Time in Patent Office: 545 Days
• Field of Search: 705/4, 705/35
• 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 an insurance network with a plurality of physicians in a healthcare practice participating therein. Exemplary computer implemented methods can include, for example, comparing data received via a 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 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, determining whether the risk of the at least one of the plurality of physicians of not receiving a predetermined reimbursement amount for the ancillary medical costs from the insurance company has been reduced responsive to recommending alternative ancillary medical procedures to the at least one of the plurality of physicians.

Claims

1. A computer implemented method of modifying the ancillary medical cost management behavior of at least one of a plurality of physicians in a healthcare practice participating in an insurance network to thereby enhance the profitability of 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, the data including at least one of 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, ancillary medical costs respective to each of the plurality of physicians, and the number of patients of each of the plurality of physicians participating in the insurance network;

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, in a third computer process, 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 to thereby reduce the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice to a predetermined level and enhance the profitability of the insurance network;

determining, in a fourth computer process, whether risk of the at least one of the plurality of physicians of not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance has been reduced responsive to recommending, in the third computer process, alternative ancillary medical procedures to the at least one of the plurality of physicians in the healthcare practice.

2. A computer implemented method as defined in claim 1 further comprising the steps of:

calculating, in a fifth 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 participating in the insurance network has decreased to the predetermined level during a preselected period of time; and

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

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

measuring, in a seventh computer process average ancillary medical costs of the healthcare practice participating in the insurance network 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 participating in the insurance network;

calculating, in the seventh 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 seventh 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 seventh 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 participating in the insurance network to thereby determine the savings attributed to services of the healthcare consultation group; and

distributing 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.

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

dividing, in an eighth 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 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;

and

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

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

wherein the data received via the communications network for each of a plurality of physicians in the healthcare practice participating in the insurance network is received from at least one ancillary medical network database associated with an ancillary medical facility;

and

wherein the computer implemented method further comprises the step of providing at least a pricing structure of the healthcare consultation group via electronic mail through the communications network.

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

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 a ninth 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.

8. A computer implemented method as defined in claim 7,

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, and 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; 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.