System and method for intelligent management of medical care

• US 7,979,289 B2
• Filed: 08/22/2008
• Issued: 07/12/2011
• Est. Priority Date: 08/24/2007
• Status: Active Grant

• Current Assignee: Medata LLC
• Original Assignee: The Callas Group, LLC
• Inventors: Callas, Constantine
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): Pauls; John A
• Application Number:
  US12/197,063
• Publication Number:
  US 20090210251A1
• Time in Patent Office: 1,054 Days
• Field of Search: 705/2, 705/4, 364/401
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/0283 Price estimation or determination
• 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 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems

Abstract

A computerized medical care system provides validation of a diagnosis of a medical condition and requested medical services for treating the medical condition. The medial care system invokes multiple filters to determine the appropriateness of the diagnosis and medical service. Real time feedback is provided based on the determination. If the medical care cannot be validated, the feedback includes the reasons for the failure to validate, and any supporting materials for the lack of validation. The feedback may also prompt the requesting entity to provide additional information to help support the medical provider'"'"'s position as to why the requested medical care is appropriate.

Claims

1. In a computerized medical care system, a method for providing pre-approval for medical services and charges associated with the medical services, the method comprising:

receiving by a server computer from a requesting device, a medical claim including a service code associated with a proposed medical service for a diagnosed condition for a patient prior to rendering the medical service by a medical provider, and a proposed charge for the medical service;

identifying by the server computer one or more filters enabled for the computerized medical care system;

applying by the server computer the identified one or more filters for the received medical claim, the identified filters accessing a historical database of patient records with historical data on medical procedures rendered to at least a plurality of other patients for the diagnosed condition, wherein the historical data includes data of past charges for the proposed medical service;

determining by the server computer whether the proposed medical service is medically necessary for the diagnosed condition and whether the proposed charge is reasonable or unreasonable, based on at least the historical data, wherein the determining whether the proposed charge is reasonable or unreasonable includes comparing the proposed charge to a threshold value selected based on the historical data of past charges for the proposed medical service for determining that the proposed charge is presumptively unreasonable if the charge is above the threshold value, but reasonable if the proposed charge is at or below the threshold value;

providing by the server computer based on the determination, feedback to the requesting device on whether the proposed medical service is medically necessary and reasonably charged prior to the rendering of the medical service by the medical provider, wherein if the proposed medical service is determined to be medically necessary and reasonably charged, the feedback includes pre-approval for the received medical claim for ensuring payment to the medical provider according to the proposed charge; and

if the proposed medical service is determined to be medically unnecessary based on at least the historical data, prompting the medical provider by the server computer to submit information justifying the proposed service for reevaluating the proposed medical service; and

if the proposed charge is determined to be unreasonable based on at least the historical data, determining by the server computer a reasonable amount that will be paid to the medical provider and informing the medical provider of the determined amount, the server computer further prompting the medical provider to submit information justifying the proposed charge for reevaluating the proposed charge.

2. The method of claim 1 further comprising:

displaying a question that should be considered in making the diagnosis of the condition;

prompting a user response to the displayed question;

receiving the user response to the displayed question;

comparing an expected response to the displayed question with the received user response; and

validating the diagnosis if the expected response matches the received user response.

3. The method of claim 1, wherein a plurality of the filters are applied one by one in sequence.

4. The method of claim 1 further comprising:

providing by the server computer a graphical user interface with a list of the one or more filters;

receiving a user selection of desired ones of the one or more filters; and

enabling each selected filter for determining whether the proposed medical service is medically necessary for the diagnosed condition, and whether the proposed charge is reasonable or unreasonable.

5. The method of claim 1, wherein the determining whether the proposed medical service is medically necessary includes:

analyzing by the server computer the historical data in the historical database on medical services rendered historically for the diagnosed condition and conditions for rendering the medical services;

identifying proposed conditions for rendering the proposed medical service;

identifying, based on the analyzed historical data, percentile distribution values for respectively the proposed medical service and the proposed conditions; and

determining that the proposed medical service is medically necessary if the identified percentile distribution values are at least equal to predetermined percentile distribution values selected by a user.

6. The method of claim 5 further comprising:

adding to the historical database information on the medical service proposed for the diagnosed condition.

7. The method of claim 5, wherein the conditions are selected from a group consisting of duration of care, number of visits, and the proposed charge for the medical service.

8. The method of claim 5, wherein the predetermined percentile distribution values are user customized.

9. The method of claim 1, wherein at least one of the one or more filters is a heat filter, and the determining of whether the proposed medical service is medically necessary based on the heat filter includes:

identifying a date of injury;

identifying a timing of the proposed medical service, wherein the proposed medical service is a heat-based therapy; and

determining that the medical service is medically necessary based on the timing of the heat-based therapy relative to the date of injury.

10. The method of claim 1, wherein at least one of the one or more filters is a rarity filter, and the determining of whether the proposed medical service is medically necessary based on the rarity filter includes:

retrieving by the server computer from the historical database the historical data of medical services historically provided for the diagnosed medical condition;

identifying a rate in which the proposed medical service was provided for the identified diagnosis based on the retrieved historical data;

identifying a threshold rate; and

determining that the proposed medical service is medically necessary based on a determination that the identified rate is equal or above the threshold rate.

11. The method of claim 10, wherein the threshold rate is user customized.

12. The method of claim 1, wherein at least one of the one or more filters is a utilization filter, and the determining of whether the proposed medical service is medically necessary based on the utilization filter includes:

receiving information on one of a number of visits and duration of care requested for rendering the proposed medical service;

analyzing the historical data in the historical database on one of a number of visits and durations of care provided historically for the diagnosed condition;

identifying one of a threshold number of visits and durations of care based on the analyzed data;

determining that the medical service is medically necessary based on a determination that one of the requested number of visits and duration of care is equal or below the identified threshold number.

13. The method of claim 1, wherein at least one of the one or more filters is a level of service filter, and the determining of whether the proposed medical service is medically necessary based on the level of service filter includes:

identifying a level of service associated with the proposed medical service;

analyzing the historical data in the historical database on levels of service provided historically for the diagnosed condition;

identifying a threshold level of service based on the analyzed data; and

determining that the medical service is medically necessary based on a determination that the identified level of service is equal or below the threshold level of service.

14. The method of claim 1, wherein at least one of the one or more filters is a billing guidelines filter, and the determining of whether the proposed charge is reasonable or unreasonable based on the billing guidelines filter includes:

identifying by the server computer a billing guideline associated with the proposed medical service; and

determining that the proposed charge is reasonable if the proposed charge complies with the identified billing guideline.

15. The method of claim 1, wherein at least one of the one or more filters is a charges filter, and the determining of whether the proposed charge is reasonable or unreasonable includes:

analyzing the historical data including total charges for the diagnosed condition;

identifying based on the analyzed historical data, a percentile distribution value for proposed total charges for the diagnosed condition; and

determining that the proposed total charges is reasonable if the percentile distribution value for the proposed total charges is equal or below a predetermined percentile distribution value.

16. The method of claim 15, wherein the predetermined percentile distribution is user customized.

17. The method of claim 1, wherein the feedback is a letter generated in real time with the determining of whether the proposed medical service is medically necessary.

18. The method of claim 1, wherein the applying of at least one of the one or more filters includes:

identifying the patient for whom the medical service is proposed;

retrieving historical data of medical care provided to the patient; and

determining based on the retrieved historical data for the patient that the proposed medical service is medically necessary for the patient if the proposed medical service is not inconsistent with prior medical services received by the patient.

19. The method of claim 1 further comprising:

identifying by the server computer a charge allowed for the proposed medical service;

comparing by the server computer the proposed charge and the charge allowed;

determining by the server computer that the proposed medical service is unreasonably charged if the proposed charge exceeds the charge allowed; and

prompting by the server computer to submit information justifying the proposed charge for reevaluating the medical claim.

20. The method of claim 1, wherein the feedback provided by the server computer includes a prompt for prompting the medical provider to provide the information.

21. The method of claim 1, wherein the threshold value for determining whether a proposed charge is reasonable or unreasonable for a first user differs from the threshold value for determining whether a proposed charge is reasonable or unreasonable for a second user.

22. The method of claim 1, wherein the threshold value is a threshold dollar amount.

23. The method of claim 22, wherein the threshold value is associated with a percentile distribution value indicating a percent of the past charges in the historical database at or below the threshold dollar amount.

24. The method of claim 23, wherein the percentile distribution value is selected by a user for determining whether the proposed charge is reasonable or unreasonable.

25. The method of claim 24, wherein the percentile distribution value is selected by the user from a plurality of possible percentile distribution values stored in the historical database.

26. The method of claim 24, wherein the selected percentile distribution value is 80%.

27. The method of claim 24, wherein the percentile distribution value selected by a first user differs from the percentile distribution value selected by a second user.

28. The method of claim 1, wherein the service code is a medical diagnosis code.

29. The method of claim 28, wherein the service code is an international classification of diseases code.

30. The method of claim 1, wherein the one or more filters are medical procedure filters.

31. The method of claim 1, wherein the one or more filters implement rules provided by one or more medical organizations.

32. The method of claim 1, wherein the one or more filters are associated with specific geographic locations.

33. The method of claim 1, wherein the one or more filters apply a first set of rules based on a first type of medical claim, and a second set of rules based on a second type of medical claim.

34. A computerized medical care system for providing pre-approval for medical services and charges associated with the medical services, the system comprising:

a processor; and

a memory operably coupled to the processor and storing program instructions therein, the processor being operable to execute the program instructions, the program instructions including;

receiving from a requesting device a medical claim including a service code associated with a proposed medical service for a diagnosed condition for a patient prior to rendering the medical service by a medical provider, and a proposed charge for the medical service;

identifying one or more filters enabled for the computerized medical care system;

applying the identified one or more filters for the received medical claim, the identified filters accessing a historical database of patient records with historical data on medical procedures rendered to at least a plurality of other patients for the diagnosed condition, wherein the historical data includes data of past charges for the proposed medical service;

determining whether the proposed medical service is medically necessary for the diagnosed condition and whether the proposed charge is reasonable or unreasonable, based on at least the historical data, wherein the determining whether the proposed charge is reasonable or unreasonable includes comparing the proposed charge to a threshold value selected based on the historical data of past charges for the proposed medical service for determining that the proposed charge is presumptively unreasonable if the charge is above the threshold value, but reasonable if the proposed charge is at or below the threshold value;

providing feedback to the requesting device on whether the proposed medical service is medically necessary and reasonably charged prior to the rendering of the medical service by the medical provider, wherein if the proposed medical service is determined to be medically necessary and reasonably charged, the feedback includes pre-approval for the received medical claim for ensuring payment to the medical provider according to the proposed charge; and

if the proposed medical service is determined to be medically unnecessary based on at least the historical data, prompting the medical provider to submit information justifying the proposed service for reevaluating the proposed medical service; and

if the proposed charge is determined to be unreasonable based on at least the historical data, determining a reasonable amount that will be paid to the medical provider and informing the medical provider of the determined amount, the program instructions further including prompting the medical provider to submit information justifying the proposed charge for reevaluating the proposed charge.

35. The system of claim 34, wherein at least one of the one or more filters is a heat filter, and the program instructions for determining of whether the proposed medical service is medically necessary based on the heat filter include program instructions for:

identifying a date of injury;

identifying a timing of the proposed medical service, wherein the proposed medical service is a heat-based therapy; and

determining that the medical service is medically necessary based on the timing of the heat-based therapy relative to the date of injury.

36. The system of claim 34, wherein at least one of the one or more filters is a rarity filter, and the program instructions for determining whether the proposed medical service is medically necessary based on the rarity filter include program instructions for:

retrieving from the historical database the historical data of medical services historically provided for the diagnosed medical condition;

identifying a rate in which the proposed medical service was provided for the identified diagnosis based on the retrieved historical data;

identifying a threshold rate; and

determining that the proposed medical service is medically necessary based on a determination that the identified rate is equal or above the threshold rate.

37. The system of claim 34, wherein at least one of the one or more filters is a utilization filter, and the program instructions for determining whether the proposed medical service is medically necessary based on the utilization filter include program instructions for:

receiving information on one of a number of visits and duration of care requested for rendering the proposed medical service;

analyzing the historical data in the historical database on one of a number of visits and durations of care provided historically for the diagnosed condition;

identifying one of a threshold number of visits and durations of care based on the analyzed data;

determining that the medical service is medically necessary based on a determination that one of the requested number of visits and duration of care is equal or below the identified threshold number.

38. The system of claim 34, wherein at least one of the one or more filters is a level of service filter, and the program instructions for determining whether the proposed medical service is medically necessary based on the level of service filter include program instructions for:

identifying a level of service associated with the proposed medical service;

analyzing the historical data in the historical database on levels of service provided historically for the diagnosed condition;

identifying a threshold level of service based on the analyzed data; and

determining that the medical service is medically necessary based on a determination that the identified level of service is equal or below the threshold level of service.

39. The system of claim 34, wherein at least one of the one or more filters is a billing guidelines filter, and the program instructions for determining whether the proposed charge is reasonable or unreasonable based on the billing guidelines filter include program instructions for:

identifying a billing guideline associated with the proposed medical service; and

determining that the proposed charge is reasonable if the proposed charge complies with the identified billing guideline.

40. The system of claim 34, wherein at least one of the one or more filters is a charges filter, and the program instructions for determining whether the proposed charge is reasonable or unreasonable include program instructions for:

analyzing the historical data including total charges for the diagnosed condition;

identifying based on the analyzed historical data, a percentile distribution value for proposed total charges for the diagnosed condition; and

determining that the proposed total charges is reasonable if the percentile distribution value for the proposed total charges is equal or below a predetermined percentile distribution value.

41. The system of claim 34, wherein the feedback is a letter configured to be generated in real time with the determining of whether the proposed medical service is medically necessary.

42. The system of claim 34, wherein the program instructions for applying at least one of the one or more filters include program instructions for:

identifying the patient for whom the medical service is proposed;

retrieving historical data of medical care provided to the patient; and

determining based on the retrieved historical data for the patient that the proposed medical service is medically necessary for the patient if the proposed medical service is not inconsistent with prior medical services received by the patient.

43. The system of claim 34, wherein the threshold value for determining whether a proposed charge is reasonable or unreasonable for a first user differs from the threshold value for determining whether a proposed charge is reasonable or unreasonable for a second user.

44. The system of claim 34, wherein the threshold value is a threshold dollar amount.

45. The system of claim 44, wherein the threshold value is associated with a percentile distribution value indicating a percent of the past charges in the historical database at or below the threshold dollar amount.

46. The system of claim 45, wherein the percentile distribution value is selected by a user for determining whether the proposed charge is reasonable or unreasonable.

47. The system of claim 45, wherein the percentile distribution value is selected by the user from a plurality of possible percentile distribution values stored in the historical database.

48. The system of claim 45, wherein the selected percentile distribution value is 80%.

49. The system of claim 45, wherein the percentile distribution value selected by a first user differs from the percentile distribution value selected by a second user.

50. The system of claim 34, wherein the service code is a medical diagnosis code.

51. The system of claim 50, wherein the service code is an international classification of diseases code.

52. The system of claim 34, wherein the one or more filters are medical procedure filters.

53. The system of claim 34, wherein the one or more filters are configured to implement rules provided by one or more medical organizations.

54. The system of claim 34, wherein the one or more filters are associated with specific geographic locations.

55. The system of claim 34, wherein the one or more filters are configured to apply a first set of rules based on a first type of medical claim, and a second set of rules based on a second type of medical claim.

56. A computerized medical care system for providing pre-approval for medical services and charges associated with the medical services, the system comprising:

a computing engine configured to receive over a data communications network a medical claim including a diagnosis code identifying diagnosis of a medical condition for a patient, a service code identifying a proposed medical service, and a proposed charge for the medical service;

a data storage device storing a historical database of patient records with historical data on medical procedures rendered to at least a plurality of other patients for the diagnosed condition, wherein the historical data includes data of past charges for the proposed medical service; and

a plurality of medical procedure filters coupled to the engine and configured to determine whether the proposed medical service is medically necessary relative to the diagnosis and whether the proposed charge is reasonable or unreasonable, based on at least the historical data, wherein the determining whether the proposed charge is reasonable or unreasonable includes comparing the proposed charge to a threshold value selected based on the historical data of past charges for the proposed medical service for determining that the proposed charge is presumptively unreasonable if the charge is above the threshold value, but reasonable if the proposed charge is at or below the threshold value,

wherein the computing engine is configured to provide feedback over the data communications network on whether the proposed medical service is medically necessary and reasonably charged based on at least the historical data on the medical procedures rendered to at least the plurality of other patients for the diagnosed condition, prior to rendering of the medical service by a medical provider, wherein if the proposed medical service is determined to be medically unnecessary based on at least the historical data, the computing engine is further configured to prompt the medical provider to submit information justifying the proposed service for reevaluating the proposed medical service, and if the proposed charge is determined to be unreasonable based on at least the historical data, the computing engine is configured to determine a reasonable amount that will be paid to the medical provider and inform the medical provider of the determined amount, the computing engine being further configured to prompt the medical provider to submit information justifying the proposed charge for reevaluating the proposed charge.

57. The system of claim 56, wherein at least one of the plurality of filters is a heat filter and the computing engine is configured to determine whether the proposed medical service is medically necessary based on the heat filter, the determining including:

identifying a date of injury;

identifying a timing of the proposed medical service, wherein the proposed medical service is a heat-based therapy; and

determining that the medical service is medically necessary based on the timing of the heat-based therapy relative to the date of injury.

58. The system of claim 56, wherein at least one of the one or more filters is a rarity filter and the computing engine is configured to determine whether the proposed medical service is medically necessary based on the rarity filter, the determining including:

retrieving from the historical database the historical data of medical services historically provided for the diagnosed medical condition;

identifying a rate in which the proposed medical service was provided for the identified diagnosis based on the retrieved historical data;

identifying a threshold rate; and

determining that the proposed medical service is medically necessary based on a determination that the identified rate is equal or above the threshold rate.

59. The system of claim 56, wherein at least one of the one or more filters is a utilization filter and the computing engine is configured to determine whether the proposed medical service is medically necessary based on the utilization filter, the determining including:

receiving information on one of a number of visits and duration of care requested for rendering the proposed medical service;

analyzing the historical data in the historical database on one of a number of visits and durations of care provided historically for the diagnosed condition;

identifying one of a threshold number of visits and durations of care based on the analyzed data;

determining that the medical service is medically necessary based on a determination that one of the requested number of visits and duration of care is equal or below the identified threshold number.

60. The system of claim 56, wherein at least one of the one or more filters is a level of service filter and the computing engine is configured to determine whether the proposed medical service is medically necessary based on the level of service filter, the determining including:

identifying a level of service associated with the proposed medical service;

analyzing the historical data in the historical database on levels of service provided historically for the diagnosed condition;

identifying a threshold level of service based on the analyzed data; and

determining that the medical service is medically necessary based on a determination that the identified level of service is equal or below the threshold level of service.

61. The system of claim 56, wherein at least one of the one or more filters is a billing guidelines filter and the computing engine is configured to determine whether the proposed charge is reasonable or unreasonable based on the billing guidelines filter, the determining including:

identifying a billing guideline associated with the proposed medical service; and

determining that the proposed charge is reasonable if the proposed charge complies with the identified billing guideline.

62. The system of claim 56, wherein at least one of the one or more filters is a charges filter and the computing engine is configured to:

analyze the historical data including total charges for the diagnosed condition;

identify based on the analyzed historical data, a percentile distribution value for proposed total charges for the diagnosed condition; and

determine that the proposed total charges is reasonable if the percentile distribution value for the proposed total charges is equal or below a predetermined percentile distribution value.

63. The system of claim 56, wherein the feedback is a letter configured to be generated in real time with the determining of whether the proposed medical service is medically necessary.

64. The system of claim 56, wherein the computing engine is further configured to:

identify the patient for whom the medical service is proposed;

retrieve historical data of medical care provided to the patient; and

determine based on the retrieved historical data for the patient that the proposed medical service is medically necessary for the patient if the proposed medical service is not inconsistent with prior medical services received by the patient.

65. The system of claim 56, wherein the threshold value for determining whether a proposed charge is reasonable or unreasonable for a first user differs from the threshold value for determining whether a proposed charge is reasonable or unreasonable for a second user.

66. The system of claim 56, wherein the threshold value is a threshold dollar amount.

67. The system of claim 66, wherein the threshold value is associated with a percentile distribution value indicating a percent of the past charges in the historical database at or below the threshold dollar amount.

68. The system of claim 67, wherein the percentile distribution value is configured to be selected by a user for determining whether the proposed charge is reasonable or unreasonable.

69. The system of claim 68, wherein the percentile distribution value is configured to be selected by the user from a plurality of possible percentile distribution values stored in the historical database.

70. The system of claim 67, wherein the selected percentile distribution value is 80%.

71. The system of claim 67, wherein the percentile distribution value selected by a first user differs from the percentile distribution value selected by a second user.

72. The system of claim 56, wherein the service code is a medical diagnosis code.

73. The system of claim 72, wherein the service code is an international classification of diseases code.

74. The system of claim 56, wherein the one or more filters are medical procedure filters.

75. The system of claim 56, wherein the one or more filters are configured to implement rules provided by one or more medical organizations.

76. The system of claim 56, wherein the one or more filters are associated with specific geographic locations.

77. The system of claim 56, wherein the one or more filters are configured to apply a first set of rules based on a first type of medical claim, and a second set of rules based on a second type of medical claim.