Computer-implemented method for grouping medical claims based upon changes in patient condition

• US 8,121,869 B2
• Filed: 08/09/2010
• Issued: 02/21/2012
• Est. Priority Date: 06/22/1995
• Status: Expired due to Fees

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Ingenix Incorporated (UnitedHealth Group Incorporated)
• Inventors: Dang, Dennis K.
• Primary Examiner(s): Cobanoglu, Dilek B
• Application Number:
  US12/852,978
• Publication Number:
  US 20100324928A1
• Time in Patent Office: 561 Days
• Field of Search: 705/2, 705/3, 600/300
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• 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 40/67 for remote operation
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

Claims

1. A computer-implemented method for processing medical claims, including the steps of:

receiving medical claims data stored into a computer memory, including at least one medical claim;

determining a diagnosis code associated with the at least one medical claim;

mapping a relationship between the diagnosis code of the at least one medical claim and one of a plurality of diagnostic episode groups, each diagnostic episode group associated with a medical condition and having a predetermined window period; and

grouping the at least one medical claim into a related diagnostic episode group having an extendable time window; and

shifting the grouping of a diagnostic episode group from a first diagnostic episode group to a second diagnostic episode group upon receiving a second medical claim having at least one diagnosis code, procedure code, or drug code associated with the second diagnostic episode group.

2. The method of claim 1, wherein the time window of the diagnostic episode group is extendible until an absence of related medical claims is detected during the predetermined window period.

3. The method of claim 2, wherein the time window is extendible by resetting the predetermined window period.

4. The method of claim 3, wherein medical claims representing chronic conditions are grouped differently than medical claims representing acute conditions.

5. The method of claim 4, wherein the medical claims data includes pharmaceutical data records.

6. The method of claim 5, wherein the diagnosis code is an ICD-9 code.

7. A system for processing medical claims data, comprising:

a processor; and

a storage medium operably coupled to the processor, wherein the storage medium stores program instructions that, when executed by the processor, cause the processor to;

receive medical claims data stored into the storage medium, including at least one medical claim;

determine a diagnosis code associated with the at least one medical claim;

map a relationship between the diagnosis code of the at least one medical claim and one of a plurality of diagnostic episode groups, each diagnostic episode group associated with a medical condition and having a predetermined window period; and

group the at least one medical claim into a related diagnostic episode group having an extendable time window; and

causing the processor to shift the grouping of a diagnostic episode group from a first diagnostic episode group to a second diagnostic episode group upon receiving a second medical claim having at least one diagnosis code, procedure code, or drug code associated with the second diagnostic episode group.

8. The system of claim 7, wherein the time window of the diagnostic episode group is extendible until an absence of related medical claims is detected during the predetermined window period.

9. The system of claim 8, wherein the time window is extendible by resetting the predetermined window period.

10. The system of claim 9, wherein medical claims representing chronic conditions are grouped differently than medical claims representing acute conditions.

11. The system of claim 10, wherein the medical claims data includes pharmaceutical data records.

12. The system of claim 11, wherein the diagnosis code is an ICD-9 code.

13. A computer readable storage medium storing instructions, which upon execution by an apparatus, causes the apparatus to perform operations comprising:

receiving medical claims data stored into a computer memory, including at least one medical claim;

determining a diagnosis code associated with the at least one medical claim;

mapping a relationship between the diagnosis code of the at least one medical claim and one of a plurality of diagnostic episode groups, each diagnostic episode group associated with a medical condition and having a predetermined window period; and

grouping the at least one medical claim into a related diagnostic episode group having an extendable time window; and

performing the operation of shifting the grouping of a diagnostic episode group from a first diagnostic episode group to a second diagnostic episode group upon receiving a second medical claim having at least one diagnosis code, procedure code, or drug code associated with the second diagnostic episode group.

14. The computer readable storage medium of claim 13, wherein the time window of the diagnostic episode group is extendible until an absence of related medical claims is detected during the predetermined window period.

15. The computer readable storage medium of claim 14, wherein the time window is extendible by resetting the predetermined window period.

16. The computer readable storage medium of claim 15, wherein the medical claims data includes pharmaceutical data records.

17. The computer readable storage medium of claim 16, wherein the diagnosis code is an ICD-9 code.