Data processing system for accurately calculating a policyholder's discount in a medical insurance plan and a method therefor

• US 8,145,500 B2
• Filed: 07/26/2005
• Issued: 03/27/2012
• Est. Priority Date: 07/26/2004
• Status: Active Grant

• Current Assignee: Vitality Group International, Inc. (Discovery Limited)
• Original Assignee: Discovery Holdings Limited (Prudential PLC)
• Inventors: Berghorst, Timothy, Matisonn, Shaun, Greenblatt, Samuel Shlomo
• Primary Examiner(s): O'Connor, Gerald J.
• Assistant Examiner(s): NGUYEN, HIEP VAN
• Application Number:
  US11/189,647
• Publication Number:
  US 20060041454A1
• Time in Patent Office: 2,436 Days
• Field of Search: 705/2
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/00 Administration; Management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment

Abstract

A data processing system for accurately calculating a discount in a medical insurance plan comprises a premiums module adapted to access data regarding the amount of premiums paid by a policyholder of the medical insurance plan for a predetermined period. A claims module is adapted to access data regarding the amount of claims paid by the medical insurance plan to the policyholder for the predetermined period, the claims module being further adapted to access data to determine if there have been any claims submitted by a policyholder which have not yet been paid, and if so to apply a set of rules to each submitted claim which has not been paid to determine if it is likely to be paid, and if the claim is likely to be paid then adding the amount of the claim to the amount of claims already paid for the predetermined period. Finally, a discount module adapted to receive data from the premiums module and the claims module and to use the data to calculate a discount amount.

Claims

1. A computer implemented method for periodically determining a policyholder'"'"'s discounted premium for a next succeeding period of a medical insurance plan comprising the steps of:

inputting into at least one computer data pertaining to (i) a medical insurance plan whereby policyholders in the plan pay periodically premiums for each succeeding period of the plan in consideration of their medical insurance claims for insured loss under the insurance plan will be paid according to the terms and conditions of the plan and the rules imposed by the plan, and (ii) a list of participating 3^rd parties and the goods and services provided which policyholders may avail themselves and receive points there for;

selecting, from data inputted into said at least one computer, at least one data pertaining to at least one policyholder, said data selected from the group consisting of;

personal and family data, premiums paid in a current period and preceding periods, medical insurance claims made, goods and services of 3^rd parties which the policyholder has availed him/her self of, preselected medical testing of the policyholder, preselected health programs followed by the policyholder and results thereof, and points accumulated by the policyholder, the points based upon participation by the policyholder in beneficial health related activities;

calculating, using said at least one computer, premiums that a policyholder shall pay for each next succeeding period of each policyholder'"'"'s medical insurance plan, based on the premium of the current period, by first determining a notional premium for the current period with no discount applied, and then, adjusting for any plan or option changes in personal and family data, and storing in memory of said at least one computer a first output indicative thereof;

calculating, using said at least one computer, for each policyholder (i) medical insurance claims paid during the current period, (ii) medical insurance claims filed and in process of resolution, and (iii) medical insurance claims filed but not yet in process of resolution, and applying plan rules inputted into said at least one computer to medical insurance claims in process of resolution and medical insurance claims not yet in process of resolution, and adjusting the policyholder'"'"'s medical insurance claims for medical insurance claims deemed likely to comply with plan rules and be paid, to obtain an adjusted total of medical insurance claims, and storing in memory of said at least one computer a second output indicative thereof;

calculating, using said at least one computer, the status level of each policyholder based on the points accumulated by the policyholder, and storing in memory of said at least one computer a third output indicative thereof;

calculating, using said at least one computer, based upon the first, second and third outputs to the processor, a discounted premium to be applied to each policyholder'"'"'s premium for the next succeeding period, and storing in memory of said at least one computer a fourth output indicative thereof; and

transforming from memory in said at least one computer to human visible form, said fourth output, by one of displaying on a display or printing.

2. Apparatus for periodically determining a policyholder'"'"'s discounted premium for a next succeeding period of a medical insurance plan comprising:

a. a data processing system comprised of a processor, a memory, an input device and a display;

b. means for implementing and storing in memory of the system (i) a medical insurance plan whereby policyholders in the plan pay periodically premiums for each succeeding period of the plan in consideration that medical insurance claims for insured loss for ill-health of the insured will be paid according to the terms and conditions of the plan and the rules imposed by the plan, and (ii) a list of participating 3^rd parties and the goods and services provided which policyholders may avail themselves and receive points there for;

c. means for recording in memory for each policyholder personal and family data, premiums paid in a current period and preceding periods, medical insurance claims made, goods and services of said participating 3^rd parties which the policyholder has availed him/her self, preselected medical testing, preselected health programs followed by the policyholder and results thereof, and all points accumulated by the policyholder;

d. means for recording in memory of the system (i) rate tables for medical insurance, (ii) risk factors, (iii) administration fees, (iv) expense allowances, (v) a points award schedule for participating 3^rd parties goods and services utilized by the policyholder, and a series of low to high graduated status levels based on points accumulated by a policyholder;

e. means for establishing a premiums module in said system for determining the premium that a policyholder shall pay for each next succeeding period of each policyholder'"'"'s medical insurance plan, based on the premium of the current period, by first determining a notional premium for the current period with no discount applied, and then, adjusting for any plan or option changes in personal and family data, and providing and storing in memory a first output indicative thereof;

f. means for establishing a medical insurance claims module in the system for determining for each policyholder (i) medical insurance claims paid during the current period, (ii) medical insurance claims filed and in process of resolution, and (iii) medical insurance claims filed but not yet in process of resolution, and applying plan rules to medical insurance claims in process of resolution and medical insurance claims not yet in process of resolution, adjusting the policyholder'"'"'s medical insurance claims for medical insurance claims deemed likely to comply with plan rules and be paid to obtain an adjusted total of medical insurance claims, and providing and storing in memory a second output indicative thereof;

g. means for establishing a bonus module in said system for determining the status level of each policyholder based on points accumulated by the policyholder, and providing and storing in memory a third output indicative thereof;

h. means for transmitting the first, second and third outputs to the processor and, based thereon, calculating a discounted premium to be charge each policyholder for the next succeeding period, and providing and storing in memory a fourth output indicative thereof; and

i. means for displaying visually said fourth output by one of displaying on a display or printing.

3. Computer readable medium storing executable instructions that when executed causes the computer to periodically determine a policyholder'"'"'s discounted premium for a next succeeding period of a medical insurance plan which has stored in memory of the computer a medical insurance plan, whereby policyholders in the plan pay periodically premiums for each succeeding period of the plan in consideration for which their medical insurance claims will be paid according to the terms and conditions of the plan, and the rules imposed by the plan:

a list of participating 3^rd parties and the goods and services provided which policyholders may avail themselves and receive points there for;

for each policyholder personal and family data, premiums paid in a current period and preceding periods, medical insurance claims made for coverage for ill-health, goods and services of said participating 3^rd parties which the policyholder has availed him/her self, preselected medical testing, preselected health programs followed by the policyholder and results thereof, and all points accumulated by the policyholder;

rate tables for medical insurance, risk factors, administration fees, expense allowances, a points award schedule for participating 3^rd parties goods and services utilized by a policyholder, and a series of low to high graduated status levels based on points accumulated by a policyholder;

a. first executable instructions that when executed determines via a premiums module the premium that a policyholder shall pay for each next succeeding period of each policyholder'"'"'s medical insurance plan, based on the premium of the current period, by first determining a notional premium for the current period with no discount applied, and then, adjusts for any plan or option changes in personal and family data, and provides and stores in memory a first output indicative thereof;

b. second executable instructions that when executed determines via a medical insurance claims module for each policyholder (i) medical insurance claims paid during the current period, (ii) medical insurance claims filed and in process of resolution, and (iii) medical insurance claims filed but not yet in process of resolution, and applies plan rules to medical insurance claims in process of resolution and medical insurance claims not yet in process of resolution and in response thereto adjusts the policyholder'"'"'s medical insurance claims for medical insurance claims deemed likely to comply with plan rules and be paid to obtain an adjusted total of medical insurance claims, and provides and stores in memory a second output indicative thereof;

c. third executable instructions that when executed determines via a bonus module the status level of each policyholder based on points accumulated by the policyholder, and provides and stores in memory a third output indicative thereof;

d. fourth executable instructions that when executed transmit the first, second and third outputs to the processor and, based thereon, calculates a discounted premium to charge each policyholder for the next succeeding period, and provides and stores in memory a fourth output indicative thereof; and

e. fifth executable instructions that when executed displays visually said fourth output by one of displaying on a display or printing.

4. A computer implemented method for determining an insurance premium for a medical insurance policy, comprising:

selecting, from data inputted into at least one computer, at least one data pertaining to at least one insured including personal information, medical insurance claims paid for treatment of health issues, medical insurance claims filed and in process of resolution, medical insurance claims not yet in process of resolution, participation in beneficial health related activities, and plan rules;

calculating, using the at least one computer and the data inputted, medical insurance claims in process of resolution and medical insurance claims not yet in process of resolution, which are likely to comply with plan rules and be payable, to obtain data pertaining to a likely medical insurance claim total;

calculating, using the at least one computer and the data inputted, data pertaining to a participation status level of each of the at least one insured, based on the participation in health related activities;

calculating, using the at least one computer and the data inputted and calculated, including data pertaining to the likely medical insurance claim total and status level, a discounted premium to be applied to the at least one insured'"'"'s premium due; and

transforming from memory in the at least one computer to human visible form, the insured'"'"'s premium due, by at least one of displaying on a display or printing;

wherein the at least one insured is incentivized to participate in health related activities, and a premium discount for the at least one insured based upon the participation reflects medical insurance claims for the insured that are likely to be paid.

5. The method of claim 4, wherein the step of calculating a likely medical insurance claim total, the likely medical insurance claim total is compared with medical insurance claims submitted by the at least one insured in a previous time period, as an error check.

6. The method of claim 4, wherein set step of calculating a likely medical insurance claim total includes the step of polling medical insurance claim data at predefined intervals.

7. The method of claim 4, wherein the step of calculating a participation status level includes assigning points to health related activities, and calculating a participation status level based on a total of points assigned based on the at least one insured'"'"'s actual participation in health related activities assigned points.

8. The method of claim 7, wherein four participation status levels are assignable.

9. The method of claim 7, wherein a group of insureds is defined, wherein points assigned to insureds in the group are different than points assigned to insureds not in the group.

10. The method of claim 4, wherein the steps of calculating are performed close in time to a renewal date of the insurance policy.

11. The method of claim 4, further including the step of calculating a change in premium resulting from a change in a plan coverage for the insured, and using the calculated resulting change in premium in the step of calculating premium due.

12. The method of claim 4, further including the step of calculating likely errors in medical insurance claims paid, medical insurance claims in process, and medical insurance claims not in process, and correcting errors using inputted plan rules, or alerting individuals using the at least one computer to resolve the errors.

13. The method of claim 4, further including the step of calculating, using the at least one computer, a likely medical insurance claim status of complete, incomplete and likely to be resolved, incomplete requiring human intervention, and incomplete.

14. The method of claim 4, wherein said step of calculating premium due calculates a lower premium due using a lower likely medical insurance claim total than a premium due using a higher likely medical insurance claim total.

15. The method of claim 4, wherein said step of calculating premium due calculates a lower premium due using a higher participation status level than a premium due using a lower participation status level.

16. The method of claim 4, wherein said step of calculating premium due is carried out at an interval selected from the group consisting of:

monthly, quarterly, biannually, and annually.

17. The method of claim 4, wherein said step of calculating premium due includes the step of splitting premium into an employer portion and an insured portion.

18. The method of claim 4, wherein a reduction in premium due is provided as cash back to the insured.

19. The method of claim 4, wherein said step of calculating premium due includes the step of smoothing premium data, to reduce the effect of volatility or discrepancy.

20. The method of claim 4, wherein said step of calculating a likely claim total includes the step of smoothing medical claim data, to reduce the effect of volatility or discrepancy.