System, method and computer program product for estimating medical costs

• US 8,005,687 B1
• Filed: 10/15/2004
• Issued: 08/23/2011
• Est. Priority Date: 10/15/2003
• Status: Active Grant

• Current Assignee: Florida Environmental Research Institute Inc., Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Ingenix Incorporated (UnitedHealth Group Incorporated)
• Inventors: Lynn, Thomas E., Pederson, Derek C.
• Primary Examiner(s): Gilligan; Luke
• Assistant Examiner(s): CHNG, JOY P
• Application Number:
  US10/966,530
• Time in Patent Office: 2,503 Days
• Field of Search: 705 2- 3
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 10/10 Office automation; Time management

Abstract

Various embodiments for estimating a cost of a medical procedure. In one example, a method may include the operations of averaging data from various geographies of the amount billed to form a national average amount billed for the medical procedure; associating the average amount billed with one or more claim data items from a health plan; grouping the claim data items from the health plan using episode classes; calculating an average amount billed for each episode class; and adjusting the average amount billed for each episode class by a geographic adjustment factor to form an estimated cost of the medical procedure.

Claims

1. A computer-implemented method for estimating medical treatment costs, comprising:

storing medical service cost data from a plurality of geographic regions and at least one health plan provider in an electronic database, wherein the stored medical service cost data comprises;

a plurality of episode class codes, wherein each episode class code is associated with an episode of care that includes all medical services associated with a particular disease, condition, procedure, or test; and

an average amount billed by health care providers and an average amount collected by healthcare providers for each episode class code under one or more health plans provided by the at least one health plan provider, wherein the average amount billed and collected for each episode class code are respectively the summed average amount billed and summed average amount collected for all medical services in the associated episode of care;

storing a geographic adjustment factor for each of the plurality of geographic regions in the electronic database, wherein the geographic adjustment factor for each region is calculated based upon relative utilization of a plurality of selected common medical services in each of the plurality of geographic regions;

using a computer processor programmed to;

receive an electronic query input by a user via a computerized input device, wherein the query includes a geographical region and a selection by the user of a disease, medical condition, procedure, or test;

identify the stored episode class code associated with the selected disease, medical condition, procedure or test;

retrieve from the stored average medical service cost data the average amount billed and average amount collected for the identified episode class code;

adjust the retrieved average amount collected and the average amount billed for the identified episode class code using the stored geographic adjustment factor corresponding to the geographic region input by the user to generate an adjusted average amount collected and an adjusted amount billed for the selected disease, medical condition, procedure or test; and

estimate a user medical treatment cost for the selected disease, medical condition, procedure or test using the adjusted average amount billed and the adjusted average amount collected; and

displaying on an electronic user interface the estimated user medical treatment cost for the selected disease, medical condition, procedure or test.

2. The method of claim 1, wherein the displayed estimated user medical treatment cost further includes a list of medical service types associated with the selected disease, medical condition, procedure or test and a cost associated with each listed medical service type.

3. The method of claim 1, wherein the estimated user medical treatment cost represents estimated user medical treatment costs occurring within a defined time period.

4. The method of claim 1, wherein the displayed estimated user medical treatment costs include estimated user medical treatment costs for insured patients using in-network healthcare providers, insured patients using out-of-network healthcare providers, and uninsured patients.