Systems, computer programs, and methods for controlling costs of a healthcare practice

• US 8,712,796 B2
• Filed: 07/31/2013
• Issued: 04/29/2014
• Est. Priority Date: 03/19/2001
• Status: Expired due to Fees

• Current Assignee: Jasos Intellectual Property LLC
• Original Assignee: Jasos Intellectual Property LLC
• Inventors: Lewis, Charles, Moore, Terrance
• Primary Examiner(s): Gilligan, Luke
• Application Number:
  US13/955,026
• Publication Number:
  US 20130346096A1
• Time in Patent Office: 272 Days
• Field of Search: 705 2- 4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/04 Forecasting or optimisation specially adapted for administrative or management purposes, e.g. linear programming or "cutting stock problem" market predictions or forecasting for commercial activities G06Q30/0202
• CPC Class Codes: G06Q 10/0637 Strategic management or analysis, e.g. setting a goal or target of an organisation; Planning actions based on goals; Analysis or evaluation of effectiveness of goals
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/10 specially adapted for electronic funds transfer [EFT] systems; specially adapted for home banking systems
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

Systems, computer programs, and methods for controlling ancillary medical costs of a healthcare practice and/or insurance network with a plurality of physicians participating therein, are provided. According to an example method, the steps include identifying one or more a plurality of physicians having ancillary medical costs that exceed a certain level to thereby identify the physician or physicians for behavior modification with respect to ancillary medical costs. The method can also include generating information identifying recommended alternative ancillary medical procedures to modify behavior of a physician or physicians with respect to management of the ancillary medical costs. The method can also determining whether the ancillary medical costs of the physician or physicians have decreased to a preselected/baseline level, and distributing a percentage of a savings attributed to the modified ancillary medical cost management behavior when the ancillary medical costs have decreased to or below the preselected/baseline level.

Claims

1. A system to manage costs of one or more physicians in an insurance network, the system comprising:

one or more databases having data of one or more physicians participating in an insurance network associated therewith, the data including one or more ancillary medical procedures used by one or more of the physicians to treat one or more patients and one or more preferred ancillary medical procedures;

one or more processors being positioned in communication with the one or more databases and being configured to process the data; and

non-transitory memory encoded with one or more computer programs operable by the one or more processors so that during operations thereof, the one or more processors being operable to perform the following steps;

determining, in a first computer process, baseline costs of one or more of the plurality of ancillary medical procedures used by the plurality of physicians to treat the plurality of patients responsive to data stored in the one or more databases, one or more of the baseline costs being determined by measuring average ancillary medical costs of the one or more ancillary medical procedures on a per-member-per-month basis, and calculating an average of the per-member-per-month basis over a preselected period of time to determine a baseline per-member-per-month of the plurality of ancillary medical costs;

identifying, in a second computer process, one or more of the physicians who has used one or more of the ancillary medical procedure that is not preferred;

generating, in a third computer process, information for the one or more physicians representative of one or more recommended alternative ancillary medical procedures that are preferred;

determining, in a fourth computer process, whether the costs of the one or more physicians have reached at least a predetermined level below a baseline over a preselected period of time;

calculating, in a fifth computer process, a preselected percentage of costs savings responsive to determining the costs of the one or more physicians have reached at least the predetermined level below the baseline, the preselected percentage of cost savings being adapted to be distributed to the one or more physicians responsive to the determined costs of the one or more physicians having reached the at least a predetermined level below the baseline;

determining, in a sixth computer process, a portion of the costs savings attributable to behavior modification of one or more of the plurality of physician by practicing the recommended one or more alternative ancillary medical procedures, the behavior modifications including one or more of;

one-on-one review of report cards, placement of one or more chart inserts, a newsletter, treatment guidelines tied to formulas, permission documentation from one or more patient'"'"'s physicians to communicate with the one or more corresponding patient, communication from one or more ancillary medical procedure provider indicating switch to new ancillary medical procedure, and generation by one or more processors of a new ancillary medical procedure with the ancillary medical procedure provider;

determining, in a seventh computer process, an amount of funds for an incentive pool configured to be distributed to the insurance network responsive to the ancillary medical costs of the one or more physicians not decreasing to the at least a predetermined level of the baseline; and

receiving, via an electronic communication network, the preselected percentage of costs savings responsive to costs of the one or more physicians having adopted the one or more recommended ancillary medical procedures.

2. A system as defined in claim 1, wherein the one or more of the physicians is identified by identifying ancillary medical costs associated with one or more of the ancillary medical procedures that fall a predetermined standard deviation away from an average ancillary medical costs from the baseline.

3. A system to manage costs of one or more physicians in an insurance network, the system comprising:

one or more databases having data of a plurality of physicians participating in an insurance network associated therewith, the data including a plurality of ancillary medical procedures used by one or more of the plurality of physicians to treat one or more of a plurality of patients, costs of one or more of the plurality of ancillary medical procedures, and a plurality of preferred ancillary medical procedures;

one or more processors being positioned in communication with the one or more databases and being configured to process the data; and

non-transitory memory encoded with one or more computer programs operable by the one or more processors so that during operations thereof, the one or more processors being operable to perform the following steps;

measuring, in a first computer process, average ancillary medical costs of one or more of the plurality of ancillary medical procedures used by the plurality of physicians to treat the plurality of patients on a per-member-per-month basis;

calculating, in a second computer process, an average of the per-member-per-month basis over a predetermined period of time to determine a baseline per-member-per-month of the plurality of ancillary medical cost;

determining, in a third computer process, a baseline-per-member-per-year using the baseline per-member-per-month of the plurality of ancillary medical costs;

identifying, in a fourth computer process, at least one of the plurality of physicians who has used one or more of the plurality of ancillary medical procedure that is not preferred;

generating, in a fifth computer process, information for the at least one of the plurality of physicians representative of one or more recommended alternative ancillary medical procedures that are preferred;

determining, in a sixth computer process, whether the costs of the plurality of physicians have reached at least a predetermined level below the baseline-per-member-per-year over a predetermined time;

calculating, in a seventh computer process, a predetermined percentage of costs savings for the plurality of physicians responsive to determining the costs of the plurality of physicians have reached at least the predetermined level below the baseline-per-member-per-year; and

determining, in an eighth computer process, a portion of the costs savings attributable to behavior modification of one or more of the plurality of physician by practicing the recommended one or more alternative ancillary medical procedures, the behavior modifications including one or more of;

one-on-one review of resort cards, placement of one or more chart inserts, a newsletter, treatment guidelines tied to formulas, permission documentation from one or more patient'"'"'s physicians to communicate with the one or more corresponding patient, communication from one or more ancillary medical procedure provider indicating switch to new ancillary medical procedure, and generation by one or more processors of a new ancillary medical procedure with the ancillary medical procedure provider.

4. A system as defined in claim 3, wherein the non-transitory memory further is encoded with one or more computer programs operable by the one or more processors to perform the step of:

determining, in a ninth computer process, an amount of funds for an incentive pool configured to be distributed to the insurance network responsive to the ancillary medical costs of the plurality of physicians not decreasing to the at least predetermined level of the baseline-per-member-per-year; and

distributing, via an electronic communication network, funds from the incentive pool to the insurance network, the funds being a second percentage of costs of the plurality of physicians responsive to the costs not reaching the predetermined level of the baseline-per-member-per-year.

5. A system to manage costs of a plurality of physicians in an insurance network, the system comprising

one or more databases having data of a plurality of physicians in a healthcare practice participating in an insurance network associated therewith, the data including a plurality of ancillary medical procedures used by one or more of the plurality of physicians to treat one or more of a plurality of patients, costs of one or more of the plurality of ancillary medical procedures, and a plurality of preferred ancillary medical procedures;

one or more processors configured to process the data; and

non-transitory memory encoded with one or more computer programs operable by the one or more processors so that during operations thereof, the one or more processors being operable to perform the following steps;

determining, in a first computer process, baseline costs of one or more the plurality of ancillary medical procedures used by the plurality of physicians to treat the plurality of patients using data stored in the one or more databases, the baseline costs being determined by measuring average ancillary medical costs of the plurality of ancillary medical procedures on a per-member-per-month basis, and

calculating an average of the per-member-per-month basis over a predetermined period of time to determine a baseline per-member-per-month of the plurality of ancillary medical cost;

identifying, in a second computer process, at least one of the plurality of physicians who has used one or more of the plurality of ancillary medical procedure that is not preferred for cost management behavior modification of one or more of the plurality of ancillary medical procedures;

generating, in a third computer process, information for the at least one of the plurality of physicians indicating recommended one or more alternative ancillary medical procedures that are preferred to modify cost management behavior of the at least one of the plurality of physicians in the healthcare practice with respect to management of ancillary medical costs;

determining, in a fourth computer process, whether the costs of the plurality of physicians have reached at least a predetermined level below the baseline over a predetermined period of time; and

calculating, in a fifth computer process, a predetermined percentage of costs savings responsive to determining the costs of the plurality of physicians have reached at least the predetermined level below the baseline, at least a portion of the costs savings being attributable to behavior modification of one or more of the plurality of physician by practicing the recommended one or more alternative ancillary medical procedures, and wherein the behavior modifications include one or more of;

one-on-one review of report cards, placement of one or more chart inserts, a newsletter, treatment guidelines tied to formulas, permission documentation from one or more patient'"'"'s physicians to communicate with the one or more corresponding patient, communication from one or more ancillary medical procedure provider indicating switch to new ancillary medical procedure, and generation by one or more processors of a new ancillary medical procedure with the ancillary medical procedure provider.

6. A system as defined in claim 5, wherein the predetermined percentage of cost savings is adapted to be distributed to the plurality of physicians responsive to the determined costs of the plurality of physicians having reached the at least the predetermined level below the baseline.

7. A system as defined in claim 6, wherein the identified at least one of the plurality of physicians has ancillary medical costs of one or more of the plurality of ancillary medical procedures that exceed a certain level.

8. A system as defined in claim 5, wherein the non-transitory memory further is encoded with one or more computer programs operable by the one or more processors to perform the step of:

calculating a billing fee structure for the plurality of physicians by multiplying the predetermined percentage of the savings by a number of patients participating in the healthcare practice and the insurance network.

9. A system as defined in claim 5, wherein the non-transitory memory further is encoded with one or more computer programs operable by the one or more processors to perform the step of:

receiving, via an electronic communication network, from the insurance network the predetermined percentage of costs savings responsive to costs of the plurality of physicians having reached the at least predetermined level below the baseline.

10. A system as defined in claim 5, wherein the non-transitory memory further is encoded with one or more computer programs operable by the one or more processors to perform the step of:

determining, in a sixth computer process, an amount of funds for an incentive pool configured to be distributed to the insurance network responsive to the ancillary medical costs of the plurality of physicians not decreasing to the at least predetermined level of the baseline-per-member-per-year.

11. A system as defined in claim 10, wherein the non-transitory memory further is encoded with one or more computer programs operable by the one or more processors to perform the step of:

distributing, via an electronic communication network, funds from the incentive pool to the insurance network, the funds being a second percentage of costs of the plurality of physicians responsive to the costs not reaching the predetermined level of the baseline-per-member-per-year.

12. A system as defined in claim 5, wherein one or more of the plurality of preferred ancillary medical procedures are based on national guidelines.

13. A system as defined in claim 5, wherein the one or more of the plurality of physicians is identified by identifying ancillary medical costs associated with one or more of the plurality of ancillary medical procedures that fall a predetermined standard deviation away from an average ancillary medical costs from the baseline.