Fully automated health plan administrator

• US 8,165,894 B2
• Filed: 04/20/2007
• Issued: 04/24/2012
• Est. Priority Date: 04/20/2006
• Status: Expired due to Fees

• Current Assignee: Jack J. Tawil
• Original Assignee: Jack J. Tawil
• Inventors: Tawil, Jack J.
• Primary Examiner(s): RANGREJ, SHEETAL
• Application Number:
  US11/738,099
• Publication Number:
  US 20070250352A1
• Time in Patent Office: 1,831 Days
• Field of Search: 705 2- 4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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 10/20 for electronic clinical trials or questionnaires
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment
• CPC Class Codes: Y02A 90/10 Information and communication technologies [ICT] supporting adaptation to climate change, e.g. for weather forecasting or climate simulation

Abstract

A system for fully automating the administration of a health plan. The system accepts inputs from enrollees, insureds, providers, insurers and vendors, but requires no physical data entry from the plan administrator. The system also features an automated methodology that measures patient treatment outcomes in terms of quality-adjusted life-years, by diagnosis and by medical treatment provider. The system also includes automated methods for: a “just-in-time” appointment scheduler, an editable archive of prototypical treatment plans, measuring the diagnostic accuracy of diagnostic physicians and for measuring the complication rate of treatment providers.

Claims

1. A system for automatically administering a health plan, comprising:

a. a processor; and

a memory in communications with said processor, the memory including program code executable by said processor providing primary data for a first database, and processing said primary data automatically into a second database, whereby said second database comprises processed data;

b. an automated health plan administrator, comprising;

i. said first database comprising primary data originating from;

enrollment and disenrollment of insured patients and dependents, enrollment and disenrollment of diagnostic physicians, enrollment and disenrollment of providers, including medical treatment providers;

self-administered surveys by insured patients;

insurers providing insurance coverage information;

vendors providing diagnostic codes and their descriptions for each of a plurality of diagnoses; and

vendors providing procedure and medical equipment codes and their description for each of a plurality of procedures and medical equipment; and

processing said primary data automatically into processed data;

ii. said second database comprising processed data;

enrollment data of insured patients, diagnostic physicians, and other providers, including medical treatment providers and;

a benefit payable in the event a procedure is prescribed and provided;

a list of medical providers available for providing said procedure, and each provider'"'"'s charge for providing said procedure; and

historical data, by said diagnostic code, comprising patient outcomes ratings that indicate a prognosis rating versus an outcomes index that is based on the recoveries of prior patients and is measured in quality-adjusted life-years, whereby the improvement consists of measuring patient outcomes in terms of quality-adjusted life-years;

iii. first processing means;

for producing for an insured patient a treatment plan that specifies the identity of said insured, at least one procedure to be provided, and a prognosis rating;

iv. second processing means for producing a treatment record that specifies at least one procedure actually provided to said insured patient and the actual charge for providing each said procedure; and

where each said procedure is selected from only one of the group;

original treatment plan;

treatment plan including at least one alternative procedure, and for which the total benefit payable for all said procedures provided in said treatment plan does not exceed the total benefit payable for said original treatment plan;

v. third processing means for processing said treatment plan and said treatment record to determine an amount payable to said medical treatment provider, equaling the lesser of the amount charged for procedures provided and the benefit payable for procedures provided; and

determining an amount payable to the policyholder of said insured'"'"'s policy, equaling the amount by which the benefit payable for all said procedures provided less the actual charges for providing said procedures exceeds zero;

c. calculating at least one recovery score for said insured patient and adjusting said outcomes index of said medical treatment provider to include said recovery score of said insured patient; and

d. accessing said second database to add said insured patient'"'"'s said prognosis rating and said recovery score, and said medical treatment provider'"'"'s said adjusted outcomes index, wherein the improvement comprises the capability of comparing the outcomes index of one medical treatment provider with the outcomes index of other medical treatment providers with respect to a given diagnosis and for patients with comparable prognosis ratings.

2. The system as claimed in claim 1, further including a schedule of benefits that is automatically constructed, comprising the following steps:

for medical treatment providers providing services within a predetermined geographic area, the amounts charged to provide a given procedure are ranked in descending order by said third processing means;

the highest price charged among the bottom X percent of said amounts charged is established as the benefit payable for said procedure; and

the benefit level for said procedure is defined as X percent and is stored in said first database, wherein the improvement comprises said third processing means applying a predetermined benefit level to a plurality of covered procedures to determine a schedule of benefits for said covered procedures.

3. The system as claimed in claim 1, wherein said amounts charged by said medical treatment providers are automatically extracted from medical claims during processing by said third processing means and stored in said second database;

further providing that amounts charged can be entered by data entry means into said second processing means, stored in said first database and processed by said third processing means into said second database.

4. The system as claimed in claim 1, further including an automatically generated comparative report for the benefit of said insured patient, comprising:

a. said procedures that are listed in said treatment plan and the benefit payable for each said procedure;

b. a plurality of medical treatment providers offering said procedures, the outcomes index of each said medical treatment provider with respect to said diagnosis and said prognosis rating of said insured patient, and the amount each said medical treatment provider charges to provide each said procedure;

c. a value chart depicting for said medical treatment providers the relationship between said outcomes index and the total amount charged for the set of services selected from the following group;

the set of all said procedures in said treatment plan, and the set of all procedures to be provided including at least one said alternative procedure; and

d. credentials and selected personal characteristics of said medical treatment providers, whereby said insured patient can receive said comparative report to compare listed treatment options after receiving said treatment plan, but prior to selecting a medical treatment provider for treatment.

5. The system as claimed in claim 1, further including an automated process for confirming in real time the eligibility of a patient to receive covered benefits under said health plan, comprising a means for paying a premium on-line and a means for confirming that said premium has been paid, comprising a record of said premium payment residing in said second database, whereby said first and said second processing means can access said second database to confirm said payment of said premium and therefore eligibility of said patient.

6. The system as claimed in claim 1, further including the automated maintenance of an electronic medical record, comprising:

processing changes of primary data in said first database, and automatically reprocessing said primary data and storing said processed data in said second database;

automatically reprocessing said processed data within said second database; and

further including an automated process for updating said first and second databases as a result of changes in;

covered benefits, enrollment, treatment plans, treatment records, procedures provided by providers, prices, medical procedures, self-administered surveys, patient outcomes and other performance measures for medical treatment providers, performance measures for diagnostic physicians, and other medical transactions.

7. The system as claimed in claim 1, further including in said first database a pairing of diagnoses with illness- and injury-related signs and symptoms, wherein said signs and symptoms that are causally related to each said diagnosis can be determined automatically.

8. The system as claimed in claim 1, further including an automated process for providing billing and claim processing information to said second database, and billing said insured patients, comprising accessing said second database, identifying said insured patients with outstanding balances due to medical treatment providers, and processing said billing and said claim processing information into processed data, whereby said insured patients can be notified regarding amounts due.

9. The system as claimed in claim 1, further including an automated process for reconciling the monetary accounts of the insurer, providers and insureds, comprising accessing said second database to further process debits and credits relating to:

insurance coverage information, including benefits payable, deductibles, co-pays;

health savings account transactions; and

balances due to providers, insurers and insureds.

10. The system as claimed in claim 1, further including an automated process for evaluating health care records to detect fraud, comprising:

selecting related treatment plans and treatment records from the group;

patient'"'"'s magnetic medium, first processing means, second processing means, second database and third processing means;

comparing said related treatment plans and treatment records for consistency; and

flagging inconsistent records for further investigation.

11. The system as claimed in claim 1, further including an automated process for updating said first and said second databases, comprising changes in:

covered benefits, enrollment, treatment plans, treatment records, master files, procedures provided by providers, amounts charged, new medical procedures, self-administered surveys, patient outcomes and other performance measures for medical treatment providers, performance measures for diagnostic physicians, and other medical data used by said system.

12. The system as claimed in claim 1, comprising automated processes for:

enrolling and disenrolling members on-line;

enrolling and disenrolling diagnostic physicians on-line;

enrolling and disenrolling medical treatment providers and other providers on-line;

producing insurance information on-line;

processing treatment plans;

processing treatment records;

processing health plan benefits;

producing comparative reports;

producing schedules of benefits;

producing real-time confirmation that a patient is eligible to receive covered benefits;

maintaining a system of electronic medical records;

disbursing funds to insurers, insureds, medical treatment providers and other providers;

billing insureds for amounts due to medical treatment providers and other providers;

reconciling monetary accounts of insurers, providers and insureds; and

updating said first and said second databases to reflect additions, deletions and revisions, and processing said additions, deletions and revisions within said second database, whereby the improvement consists of automating and integrating all essential processes that are required to administer a health plan in a fully automated mode.

13. The system as claimed in claim 1, further comprising:

a set of Reference Recovery Functions (RRFs) produced from historical patient data;

generating a predicted recovery score for a patient using the said set of RRFs;

computing an actual recovery score for said patient using a set of the patient'"'"'s data with the said set of RRFs; and

calculating an outcomes index by using said predicted recovery scores with said actual recovery scores for a plurality of patients with comparable prognosis ratings.

14. The system as claimed in claim 1, the system further enabled to include an automated process for maintaining an archive of editable treatment plan prototypes, comprising prior treatment plans from which identifying information has been excluded, and which may be used in whole or in part to produce a new treatment plan, whereby the time and effort required to produce a new treatment plan is reduced.

15. The system as claimed in claim 1, comprising providing an automated process for evaluating quantitatively a diagnostic accuracy index for a diagnostic physician, including for each treatment plan the steps:

assigning at least one diagnostic code to a patient;

assigning a probability that each said diagnostic code predicts the likelihood that said diagnostic code corresponds to the episode of illness or injury of said patient;

determining an accuracy score based on said diagnostic codes, said probabilities, said patient'"'"'s final diagnosis, and elapsed time between said patient'"'"'s initial office visit for said treatment plan and assignment of said final diagnosis; and

computing for each said diagnostic physician a diagnostic accuracy index based on said accuracy scores produced over a predetermined recent period, whereby said diagnostic physicians'"'"' diagnoses are rated with respect to predictive accuracy and timeliness, and can be compared with said diagnostic accuracy indices of other diagnostic physicians.

16. The system as claimed in claim 1, the system further enabled to perform automatically producing a complications index for a medical treatment provider, including the steps:

assigning to a treatment plan at least one possible complication that could occur during the administering of said treatment plan;

assigning a probability that each said complication will occur during administering said treatment plan;

determining a complication score based on the actual occurrence of said complications and their respective said probabilities; and

computing for each said medical treatment provider a complications index based on said complication scores produced over a predetermined recent period, whereby said medical treatment providers'"'"' complications are rated with respect to frequency, severity and predictive accuracy and can be compared with said complication indices of other medical treatment providers.

17. The system as claimed in claim 1, the system further enabled to perform automatically the steps of providing an automated just-in-time appointment scheduler for a medical service provider, comprising a processing means that:

stores the current day'"'"'s schedule of appointments;

stores the sign-in time of each patient;

stores the time at which said medical service provider starts reviewing the electronic medical records of each scheduled patient; and

, when queried by a scheduled patient by means of a communications device, said processing means computes and reports to said scheduled patient an updated appointment time for said patient.

18. The method as claimed in claim 1, providing in said first database the pairing of diagnoses with illness- and injury-related signs and symptoms, wherein said signs and symptoms that are causally related to each said diagnosis can be determined automatically.

19. A method for automatically administering a health plan, comprising:

a. providing primary data to a first database originating from;

enrollment and disenrollment of insured patients and dependents, enrollment and disenrollment of diagnostic physicians, enrollment and disenrollment of providers, including medical treatment providers;

self-administered surveys by insured patients;

from insurers providing insurance coverage information;

vendors providing diagnostic codes and their descriptions for each of a plurality of diagnoses; and

vendors providing procedure and medical equipment codes and their description for each of a plurality of procedures and medical equipment; and

processing said primary data automatically into processed data;

b. providing processed data to a second database, comprising;

enrollment data of insured patients, diagnostic physicians, and medical treatment providers and other providers;

a benefit payable in the event a procedure is prescribed and provided;

a list of medical treatment providers available for providing said procedure and each provider'"'"'s charge for providing said procedure; and

historical data, by said diagnostic code, comprising patient outcomes ratings that indicate a prognosis rating versus an outcomes index that is based on the recoveries of prior patients and is measured in quality-adjusted life-years, whereby the improvement consists of measuring patient outcomes in terms of quality-adjusted life-years;

c. providing a first processing means, comprising;

producing for an insured patient a treatment plan that specifies the identity of said insured, at least one procedure to be provided, a prognosis rating and said benefit payable;

d. providing a second processing means, comprising;

producing a treatment record that specifies at least one procedure actually provided to said insured patient and the actual charge for providing each said procedure; and

where each said procedure is selected from the group;

original treatment plan;

treatment plan including at least one alternative procedure, and for which the total benefit payable for all said procedures provided in said treatment plan does not exceed the total benefit payable for said original treatment plan;

e. providing a third processing means, comprising;

processing said treatment plan and said treatment record to determine an amount payable to said medical treatment provider, equaling the lesser of the amount charged for procedures provided and the benefit payable for each said procedure provided; and

determining an amount payable to the policyholder of said insured'"'"'s policy, equaling the amount by which the benefit payable for all said procedures provided less the actual charges for providing said procedures exceeds zero.

20. The method as claimed in claim 19, providing automatically generating a schedule of benefits, comprising the following steps:

for medical treatment providers providing services within a predetermined geographic area, the amounts charged to provide a given procedure are ranked in descending order by said third processing means;

the highest price charged among the bottom X percent of said amounts charged is established as the benefit payable for said procedure; and

the benefit level for said procedure is defined as X percent and is stored in said first database, wherein the improvement comprises said third processing means applying a predetermined benefit level to a plurality of covered procedures to determine a schedule of benefits for said covered procedures.

21. The method as claimed in claim 19, comprising providing amounts charged by said medical treatment providers that are automatically extracted from medical claims during processing by said third processing means and stored in said second database;

further providing that amounts charged can be entered by data entry means into said second processing means, stored in said first database and processed by said third processing means into said second database.

22. The method as claimed in claim 19, providing an automatically generated comparative report for the benefit of said insured patient, comprising:

a. listing said procedures that are in said treatment plan and the benefit payable for each said procedure;

b. listing a plurality of medical treatment providers offering said procedures, the outcomes index of each said medical treatment provider with respect to said diagnosis and said prognosis rating of said insured patient, and the amount each said medical treatment provider charges to provide each said procedure;

c. presenting a value chart depicting for said medical treatment providers the relationship between said outcomes index and the total amount charged for the set of services selected from the following group;

the set of all said procedures in said treatment plan, and the set of all procedures to be provided including at least one said alternative procedure; and

d. listing said credentials and selected personal characteristics of said medical treatment providers,

whereby said insured patient can receive said comparative report to compare listed treatment options after receiving said treatment plan, but prior to selecting a medical treatment provider for treatment.

23. The method as claimed in claim 19, providing an automated process for confirming in real time the eligibility of a patient to receive covered benefits under said health plan, comprising a means for paying a premium on-line and a means for confirming that said premium has been paid, comprising a record of said premium payment residing in said second database, whereby said first and said second processing means can access said second database to confirm said payment of said premium and therefore eligibility of said patient.

24. The method as claimed in claim 19, providing an automated process for maintaining an electronic medical record, comprising:

processing changes of primary data in said first database, automatically reprocessing said primary data and storing said processed data in said second database; and

automatically reprocessing said processed data within said second database; and

further providing an automated process for updating said first and second databases as a result of changes in;

covered benefits, enrollment, treatment plans, treatment records, procedures provided by providers, prices, medical procedures, self-administered surveys, patient outcomes and other performance measures for medical treatment providers, performance measures for diagnostic physicians, and other medical transactions.

25. The method as claimed in claim 19, providing an automated process for providing billing and claim processing information to said second database, and billing said insured patients, comprising accessing said second database, identifying said insured patients with outstanding balances due to medical treatment providers, and processing said billing and said claim processing information into processed data, whereby said insured patients can be notified regarding amounts due.

26. The method as claimed in claim 19, providing an automated process for reconciling the monetary accounts of the insurer, providers and insureds, comprising accessing said second database to further process debits and credits relating to:

insurance coverage information, including benefits payable, deductibles, co-pays, health savings account transactions and balances due to providers, insurers and insureds.

27. The method as claimed in claim 19, further providing an automated process for evaluating health care records to detect fraud, comprising:

selecting related treatment plans and treatment records from the group;

patient'"'"'s magnetic medium, first processing means, second processing means, second database and third processing means;

comparing said related treatment plans and treatment records for consistency; and

flagging inconsistent records for further investigation.

28. The method as claimed in claim 19, further providing an automated process for updating said first and said second databases, comprising changes in:

covered benefits, enrollment, treatment plans, treatment records, master files, procedures provided by providers, amounts charged, new medical procedures, self-administered surveys, patient outcomes and other performance measures for medical treatment providers, performance measures for diagnostic physicians, and other medical data used by said system.

29. The method as claimed in claim 19, comprising providing automated processes for:

enrolling and disenrolling members on-line;

enrolling and disenrolling diagnostic physicians on-line;

enrolling and disenrolling medical treatment providers on-line;

producing insurance information on-line;

processing treatment plans;

processing treatment records;

processing health plan benefits;

producing comparative reports;

producing schedules of benefits;

producing real-time confirmation that a patient is eligible to receive covered benefits;

maintaining a system of electronic medical records;

disbursing funds to insureds, medical treatment providers and other providers;

billing insureds for amounts due to medical treatment providers and other providers;

reconciling monetary accounts of insurers, providers and insureds; and

updating said first and said second databases to reflect additions, deletions and revisions, and processing said additions, deletions and revisions within said second database, whereby the improvement consists of automating and integrating all essential processes that are required to administer a health plan in a fully automated mode.

30. The method as claimed in claim 19, further comprising:

creating a set of Reference Recovery Functions (RRFs) from historical patient data;

generating a predicted recovery score for a patient using the said set of RRFs;

generating an actual recovery score for said patient using a set of the patient'"'"'s data with the said set of RRFs; and

calculating an outcomes index by using said predicted recovery scores with said actual recovery scores for a plurality of patients with comparable prognosis ratings.

31. The method as claimed in claim 19, comprising providing an automated process for maintaining an archive of editable treatment plan prototypes, comprising prior treatment plans from which identifying information has been excluded;

and which may be used in whole or in part to produce a new treatment plan, whereby the time and effort required to produce a new treatment plan is reduced.

32. The method as claimed in claim 19, comprising providing an automated process for evaluating quantitatively a diagnostic accuracy index for a diagnostic physician, including for each treatment plan the steps:

assigning at least one diagnostic code to a patient;

assigning a probability that each said diagnostic code predicts the likelihood that said diagnostic code corresponds to the episode of illness or injury of said patient;

determining an accuracy score based on said diagnostic codes, said probabilities, said patient'"'"'s final diagnosis, and elapsed time between said patient'"'"'s initial office visit for said treatment plan and assignment of said final diagnosis; and

computing for each said diagnostic physician a diagnostic accuracy index based on said accuracy scores produced over a predetermined recent period, whereby said diagnostic physicians'"'"' diagnoses are rated with respect to predictive accuracy and timeliness, and can be compared with said diagnostic accuracy indices of other diagnostic physicians.

33. The method as claimed in claim 19, comprising providing an automated process for producing a complications index for a medical treatment provider, including the steps:

assigning to a treatment plan at least one possible complication that could occur during the administering of said treatment plan;

assigning a probability that each said complication will occur during administering said treatment plan;

determining a complication score based on the actual occurrence of said complications and their respective said probabilities; and

computing for each said medical treatment provider a complications index based on said complication scores produced over a predetermined recent period, whereby said medical treatment providers'"'"' complications are rated with respect to frequency, severity and predictive accuracy and can be compared with said complication indices of other medical treatment providers.

34. The method as claimed in claim 19, comprising providing an automated just-in-time appointment scheduler for a medical service provider, comprising a processing means that:

stores the current day'"'"'s schedule of appointments;

stores the sign-in time of each patient;

stores the time at which said medical service provider starts reviewing the electronic medical records of each scheduled patient; and

, when queried by a scheduled patient by means of a communications device, said processing means computes and reports to said scheduled patient an updated appointment time for said patient.