Outcomes based service provider networks

• US 8,719,058 B2
• Filed: 12/02/2010
• Issued: 05/06/2014
• Est. Priority Date: 12/02/2010
• Status: Active Grant

• Current Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Original Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Inventors: Bonner, Robert E., Pagano, Joseph D., Bohn, William J.
• Primary Examiner(s): Maguire, Lindsay M.
• Application Number:
  US12/958,704
• Publication Number:
  US 20120143629A1
• Time in Patent Office: 1,251 Days
• Field of Search: 705/4
• US Class Current: 705/4
• 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

A system and method are provided for determining a composition of a service provider network for providing services according to a workers'"'"' compensation insurance plan. The system and method acquires claim information, which describes workers'"'"' compensation claims and medical service providers, and determines a metric value for each of the medical service providers, adjusts the metric values, assigns scores based on the adjusted metric values, determines an average of the assigned scores, and generates results data based on the assigned scores. The results data indicates, for each of the medical service providers, whether the medical service provider should be included in the service provider network. The service provider metrics include a metric that relates to an amount paid per claim and a percentage of claims that involved lost time.

Claims

1. A system for determining a composition of a service provider network for providing services according to a workers'"'"' compensation insurance plan, the system comprising:

a computer-readable storage medium that stores claim information, which describes;

workers'"'"' compensation claims; and

medical service providers that provided medical services related to the workers'"'"' compensation claims including numerical information related to a patients'"'"' satisfaction with the medical services provided;

at least one processor that;

determines, for each of the medical service providers included in the stored claim information, a metric value for each of a plurality of service provider metrics based on the stored claim information, wherein the service provider metrics include;

the information related to the patient view of the medical services provided;

a metric that relates to an amount paid per claim; and

a percentage of claims that involved lost time;

adjusts the metric values based on one or more adjustment parameters;

assigns scores to each of the medical service providers based on the adjusted metric values;

determines an average of the assigned scores for each of the medical service providers; and

generates results data based on the determined averages of the assigned scores, wherein the results data indicates, for each of the medical service providers, whether the medical service provider is included in the service provider network, and wherein the medical service providers with generated results below a threshold are not included in the service provider network; and

a display device that displays the results data.

2. The system of claim 1, wherein the service provider metrics further include one or more of:

an average number of disability days; and

a percentage of claims that involved legal activity.

3. The system of claim 1, wherein the service provider metrics further include one or more of:

an average claimant satisfaction;

an average claims adjuster satisfaction; and

an average employer satisfaction.

4. The system of claim 1, wherein the one or more adjustment parameters include:

a type of injury associated with claims handled by the medical service provider;

an age of claimants for claims handled by the medical service provider; and

an age of claims handled by the medical service provider.

5. The system of claim 4, wherein the at least one processor is configured to adjust the metric values based on the one or more adjustment parameters by:

determining an average metric value for claims with a given type of injury; and

adjusting the metric values based on the determined average metric value.

6. The system of claim 4, wherein the at least one processor is configured to adjust the metric values based on the one or more adjustment parameters by:

determining an average metric value for claims with claimants of a given age; and

adjusting the metric values based on the determined average metric value.

7. The system of claim 4, wherein the at least one processor is configured to adjust the metric values based on the one or more adjustment parameters by:

determining an average metric value for claims of a given age; and

adjusting the metric values based on the determined average metric value.

8. The system of claim 1, wherein the at least one processor is further configured to determine whether,

for each of the medical service providers, the medical service provider is included in the service provider network or not based on

whether the average of the assigned scores for the medical service provider is above or below a threshold value.

9. The system of claim 1, further comprising:

at least one communication interface, configured to receive one or more search parameters that indicate a search for a medical service provider to obtain medical services;

wherein the at least one processor is configured to generate search response information, wherein the search response information

includes information related to medical service providers that are included in the service provider network, and

does not include information related to medical service providers that are not included in the service provider network; and

wherein the at least one communication interface is further configured to transmit the search response information.

10. The system of claim 1, wherein the at least one processor is configured to assign the scores to each of the medical service providers based on percentage ranges for each of the service provider metrics and scores that correspond to each of the percentage ranges, wherein the percentage ranges and corresponding scores include:

a percentage range of ninety percent to one hundred percent, which corresponds to a score of five;

a percentage range of seventy-five percent to ninety percent, which corresponds to a score of four;

a percentage range of fifty percent to seventy-five percent, which corresponds to a score of three;

a percentage range of twenty-five percent to fifty percent, which corresponds to a score of two;

a percentage range of ten percent to twenty-five, which corresponds to a score of one; and

a percentage range of zero percent to ten percent, which corresponds to a score of zero.

11. A computer-implemented method for determining a composition of a service provider network, the method comprising:

a computer-readable storage medium storing claim information, wherein the claim information describes;

workers'"'"' compensation claims; and

medical service providers that provided medical services related to the workers'"'"' compensation claims including numerical information related to patients'"'"' satisfaction with the medical services provided;

at least one processor determining, for each of the medical service providers, a metric value for each of a plurality of service provider metrics based on the claim information, wherein the service provider metrics include;

the information related to the patient view of the medical services provided;

a metric that relates to an amount paid per claim; and

a percentage of claims that involved lost time;

the at least one processor adjusting the metric values based on one or more adjustment parameters;

the at least one processor assigning scores to each of the medical service providers based on the adjusted metric values;

the at least one processor determining averages of the assigned scores for each of the medical service providers; and

the at least one processor generating results data based on the determined averages of the assigned scores, wherein the results data indicates, for each of the medical service providers, whether the medical service provider is included in the service provider network, and wherein the medical service providers with generated results below a threshold are not included in the service provider network; and

a display device displaying the results data.

12. The method of claim 11, wherein the service provider metrics further include one or more of:

an average number of disability days; and

a percentage of claims that involved legal activity.

13. The method of claim 11, wherein the service provider metrics further include one or more of:

an average claimant satisfaction;

an average claims adjuster satisfaction; and

an average employer satisfaction.

14. The method of claim 11, wherein the one or more adjustment parameters include:

a type of injury associated with claims handled by the medical service provider;

an age of claimants for claims handled by the medical service provider; and

an age of claims handled by the medical service provider.

15. The method of claim 14, wherein the adjusting the metric values based on the one or more adjustment parameters includes:

determining an average metric value for claims with a given type of injury; and

adjusting the metric values based on the determined average metric value.

16. The method of claim 14, wherein the adjusting the metric values based on the one or more adjustment parameters includes:

determining an average metric value for claims with claimants of a given age; and

adjusting the metric values based on the determined average metric value.

17. The method of claim 14, wherein the adjusting the metric values based on the one or more adjustment parameters includes:

determining an average metric value for claims of a given age; and

adjusting the metric values based on the determined average metric value.

18. The method of claim 11, further comprising:

the at least one processor determining whether, for each of the medical service providers, the medical service provider is included in the service provider network or not based on whether the average of the assigned scores for the medical service provider is above or below a threshold value.

19. The method of claim 11, further comprising:

at least one communication interface receiving one or more search parameters that indicate a search for a medical service provider to obtain medical services;

the at least one processor generating search response information, wherein the search response information

includes information related to medical service providers that are included in the service provider network, and

does not include information related to medical service providers that are not included in the service provider network; and

the at least one communication interface transmitting the search response information.

20. The method of claim 11, wherein the assigning the scores to each of the service providers is performed based on percentage ranges for each of the service provider metrics and scores that correspond to each of the percentage ranges, wherein the percentage ranges and corresponding scores include:

a percentage range of ninety percent to one hundred percent, which corresponds to a score of five;

a percentage range of seventy-five percent to ninety percent, which corresponds to a score of four;

a percentage range of fifty percent to seventy-five percent, which corresponds to a score of three;

a percentage range of twenty-five percent to fifty percent, which corresponds to a score of two;

a percentage range of ten percent to twenty-five, which corresponds to a score of one; and

a percentage range of zero percent to ten percent, which corresponds to a score of zero.

21. A computer-readable medium having processor-executable instructions stored thereon which, when executed by at least one processor, will cause the at least one processor to perform a method for determining a composition of a service provider network, the method comprising:

receiving claim information, wherein the claim information describes;

workers'"'"' compensation claims; and

medical service providers that provided medical services related to the workers'"'"' compensation claims including numerical information related to at least one of a patients'"'"' satisfaction with the medical services provided;

determining, for each of the medical service providers, a metric value for each of a plurality of service provider metrics based on the claim information, wherein the service provider metrics include;

the information related to the patient view of the medical services provided;

a metric that relates to an amount paid per claim; and

a percentage of claims that involved lost time;

adjusting the metric values based on one or more adjustment parameters;

assigning scores to each of the medical service providers based on the adjusted metric values;

determining averages of the assigned scores for each of the medical service providers; and

generating results data based on the determined averages of the assigned scores, wherein the results data indicates, for each of the medical service providers, whether the medical service provider is included in the service provider network, and wherein the medical service providers with generated results below a threshold are not included in the service provider network; and

displaying the results data via a display device.

22. The computer-readable medium of claim 21, wherein the service provider metrics further include one or more of:

an average number of disability days; and

a percentage of claims that involved legal activity.

23. The computer-readable medium of claim 21, wherein the service provider metrics further include one or more of:

an average claimant satisfaction;

an average claims adjuster satisfaction; and

an average employer satisfaction.

24. The computer-readable medium of claim 21, wherein the one or more adjustment parameters include:

a type of injury associated with claims handled by the medical service provider;

an age of claimants for claims handled by the medical service provider; and

an age of claims handled by the medical service provider.

25. The computer-readable medium of claim 24, wherein the adjusting the metric values based on the one or more adjustment parameters includes:

determining an average metric value for claims with a given type of injury; and

adjusting the metric values based on the determined average metric value.

26. The computer-readable medium of claim 24, wherein the adjusting the metric values based on the one or more adjustment parameters includes:

determining an average metric value for claims with claimants of a given age; and

adjusting the metric values based on the determined average metric value.

27. The computer-readable medium of claim 24, wherein the adjusting the metric values based on the one or more adjustment parameters includes:

determining an average metric value for claims of a given age; and

adjusting the metric values based on the determined average metric value.

28. The computer-readable medium of claim 21, wherein the method further comprises:

determining whether, for each of the medical service providers, the medical service provider is included in the service provider network or not based on whether the average of the assigned scores for the medical service provider is above or below a threshold value.

29. The computer-readable medium of claim 21, wherein the method further comprises:

receiving one or more search parameters that indicate a search for a medical service provider to obtain medical services via at least one communication interface;

generating search response information, wherein the search response information

includes information related to medical service providers that are included in the service provider network, and

does not include information related to medical service providers that are not included in the service provider network; and

transmitting the search response information via the at least one communication interface.

30. The computer-readable medium of claim 21, wherein the assigning the scores to each of the service providers is performed based on percentage ranges for each of the service provider metrics and scores that correspond to each of the percentage ranges, wherein the percentage ranges and corresponding scores include:

a percentage range of ninety percent to one hundred percent, which corresponds to a score of five;

a percentage range of seventy-five percent to ninety percent, which corresponds to a score of four;

a percentage range of fifty percent to seventy-five percent, which corresponds to a score of three;

a percentage range of twenty-five percent to fifty percent, which corresponds to a score of two;

a percentage range of ten percent to twenty-five, which corresponds to a score of one; and

a percentage range of zero percent to ten percent, which corresponds to a score of zero.