Systems, methods, and program products for calculating shared savings for a self-insured health care plan

• US 9,846,914 B1
• Filed: 06/20/2014
• Issued: 12/19/2017
• Est. Priority Date: 06/20/2013
• Status: Active Grant

• Current Assignee: The Feinstein Institutes For Medical Research
• Original Assignee: Northwell Health, Inc.
• Inventors: Murray, Alan J., Molloy, Joseph F.
• Primary Examiner(s): Apple, Kirsten
• Application Number:
  US14/310,919
• Time in Patent Office: 1,278 Days
• Field of Search: 705 35, 705 36 R
• CPC Class Codes: G06Q 30/0207 Discounts or incentives, e.g. coupons or rebates
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A computer implemented method and system is provided for managing one or more self-insured plans, where healthcare provider'"'"'s discount rate may be dynamically or retroactively adjusted during each plan period based at least in part on, for example, the rate of utilization of in-network or in-system providers by a plurality of respective plan participants. In exchange for the discounts on its services, shared savings may be calculated and paid to the provider after the end of each plan period based at least in part on lower than expected claims.

Claims

1. A computer implemented method comprising:

(a) maintaining, by a computer system including at least one computer, a database stored in a memory comprising;

(1) electronic claims data related to claims incurred by a plurality of respective plan participants in a self-insured healthcare plan;

(2) electronic utilization data related to utilization of in-network or in-system healthcare providers by the plurality of respective plan participants;

(3) electronic targeted medical expense data related to a targeted medical expense amount for a plan period of the self-insured healthcare plan;

(4) electronic healthcare provider discount rate data related to a healthcare provider discount rate;

(b) setting, by the computer system, the targeted medical expense amount;

(c) after each quarter of the plan period, determining, by the computer system, the utilization data for the quarter based at least in part on;

(1) the plan participants'"'"' claim counts involving the in-network or in-system healthcare providers during the quarter,

(2) the plan participants'"'"' claim volume involving the in-network or in-system healthcare providers during the quarter,

(3) a number of the plan participants'"'"' hospitalizations involving the in-network or in-system healthcare providers during the quarter,

(4) a number of the plan participants'"'"' visits to the in-network or in-system healthcare providers during the quarter, and

(5) a number of the plan participants using the in-network or in-system healthcare providers compared to a number of the plan participants not using the in-network or in-system healthcare providers during the quarter;

(d) adjusting, by the computer system, the healthcare provider discount rate based at least in part on the utilization data for the quarter;

(e) adjusting, by the computer system, the claims incurred by the plurality of respective plan participants during the each quarter of the plan period based at least in part on the corresponding adjusted healthcare provider discount rate so that the adjusted claims are controlled by the healthcare provider discount rate; and

(f) processing, by the computer system, pending claims of the in-network or in-system healthcare providers for the quarter based at least in part on the adjusted claims.

2. The computer implemented method of claim 1, further comprising:

(g) after the end of the plan period, calculating, by the computer system, the sum of the claims, including the adjusted claims, incurred by the plurality of respective plan participants during the plan period;

(h) comparing, by the computer system, the sum with the targeted medical expense amount to calculate a surplus; and

(i) determining, by the computer system, shared savings based at least in part on the surplus.

3. The computer implemented method of claim 1, wherein the step of setting the targeted medical expense amount comprises:

determining, by the computer system, one or more of a maximum claims liability and an expected claims amount; and

adjusting, by the computer system, the targeted medical expense amount for the plan period based at least in part on the one or more of a maximum claims liability and an expected claims amount.

4. The computer implemented method of claim 1, further comprising collecting the utilization data in real time during the plan period.

5. The computer implemented method of claim 1, further comprising:

during the plan period, collecting, by the computer system, the claims data;

at each time in one or more points during the plan period, calculating, by the computer system, an expected claims value for the plan period based at least in part on the subtotal of the claims data collected to date;

calculating, by the computer system, a projected value of shared savings by comparing the expected claims value with the targeted medical expense amount; and

adjusting, by the computer system, the healthcare provider discount rate based at least in part on the projected value of shared savings.

6. A computer implemented method comprising:

(a) maintaining, by a computer system including at least one computer, a database stored in a memory comprising;

(1) electronic claims data related to claims incurred by a plurality of respective plan participants in a self-insured healthcare plan;

(2) electronic utilization data related to utilization of in-network or in-system healthcare providers by the plurality of respective plan participants;

(3) electronic targeted medical expense data related to a targeted medical expense amount for a plan period of the self-insured healthcare plan;

(4) electronic healthcare provider discount rate data related to a healthcare provider discount rate;

(b) setting, by the computer system, the targeted medical expense amount;

(c) during the plan period, obtaining, by the computer system, data related to each one of claims incurred by the plurality of respective plan participants;

(d) after each quarter of the plan period, determining, by the computer system, the utilization data for the quarter based at least in part on;

(1) the plan participants'"'"' claim counts involving the in-network or in-system healthcare providers during the quarter,

(2) the plan participants'"'"' claim volume involving the in-network or in-system healthcare providers during the quarter,

(3) a number of the plan participants'"'"' hospitalizations involving the in-network or in-system healthcare providers during the quarter,

(4) a number of the plan participants'"'"' visits to the in-network or in-system healthcare providers during the quarter, and

(5) a number of the plan participants using the in-network or in-system healthcare providers compared to a number of the plan participants not using the in-network or in-system healthcare providers during the quarter;

(e) adjusting, by the computer system, the healthcare provider discount rate based at least in part on the utilization data for the quarter;

(f) adjusting, by the computer system, the each one of the claims based at least in part on the corresponding adjusted healthcare provider discount rate so that the adjusted claims are controlled by the healthcare provider discount rate; and

(g) processing, by the computer system, pending claims of the in-network or in-system healthcare providers for the quarter based at least in part on the adjusted claims.

7. The computer implemented method of claim 6, further comprising:

(h) after the end of the plan period, calculating, by the computer system, the sum of the adjusted claims incurred by the plurality of respective plan participants during the plan period;

(i) comparing, by the computer system, the sum with the targeted medical expense amount to calculate a surplus; and

(j) determining, by the computer system, shared savings based at least in part on the surplus.

8. The computer implemented method of claim 6, wherein the step of setting the targeted medical expense amount comprises:

determining, by the computer system, one or more of a maximum claims liability and an expected claims amount; and

adjusting, by the computer system, the targeted medical expense amount for the plan period based at least in part on the one or more of a maximum claims liability and an expected claims amount.

9. The computer implemented method of claim 6, further comprising collecting the utilization data in real time during the plan period.

10. The computer implemented method of claim 6, further comprising:

during the plan period, collecting, by the computer system, the claims data;

at each time in one or more points during the plan period, calculating, by the computer system, an expected claims value for the plan period based at least in part on the subtotal of the claims data collected to date;

calculating, by the computer system, a projected value of shared savings by comparing the expected claims value with the targeted medical expense amount; and

adjusting, by the computer system, the healthcare provider discount rate based at least in part on the projected value of shared savings.

11. A computer system comprising:

one or more memories;

one or more processors operatively connected to the one or more memories; and

one or more computer readable media operatively connected to the one or more processors and having stored thereon computer instructions for carrying out the steps of;

(a) maintaining, by the computer system, a database stored in the one or more memories, the database comprising;

(1) electronic claims data related to claims incurred by a plurality of respective plan participants in a self-insured healthcare plan;

(2) electronic utilization data related to utilization of in-network or in-system healthcare providers by the plurality of respective plan participants;

(3) electronic targeted medical expense data related to a targeted medical expense amount for a plan period of the self-insured healthcare plan;

(4) electronic healthcare provider discount rate data related to a healthcare provider discount rate;

(b) setting, by the computer system, the targeted medical expense amount;

(c) during the plan period, obtaining, by the computer system, data related to each one of claims incurred by the plurality of respective plan participants;

(d) after each quarter of the plan period, determining, by the computer system, the utilization data for the quarter based at least in part on;

(1) the plan participants'"'"' claim counts involving the in-network or in-system healthcare providers during the quarter,

(2) the plan participants'"'"' claim volume involving the in-network or in-system healthcare providers during the quarter,

(3) a number of the plan participants'"'"' hospitalizations involving the in-network or in-system healthcare providers during the quarter,

(4) a number of the plan participants'"'"' visits to the in-network or in-system healthcare providers during the quarter, and

(5) a number of the plan participants using the in-network or in-system healthcare providers compared to a number of the plan participants not using the in-network or in-system healthcare providers during the quarter;

(e) adjusting, by the computer system, the healthcare provider discount rate based at least in part on the utilization data for the quarter;

(f) adjusting, by the computer system, the each one of the claims based at least in part on the corresponding adjusted healthcare provider discount rate so that the adjusted claims are controlled by the healthcare provider discount rate; and

(g) processing, by the computer system, pending claims of the in-network or in-system healthcare providers for the quarter based at least in part on the adjusted claims.

12. The computer system of claim 11, wherein the computer instructions further carry out the steps of:

(h) after the end of the plan period, calculating, by the computer system, the sum of the adjusted claims incurred by the plurality of respective plan participants during the plan period;

(i) comparing, by the computer system, the sum with the targeted medical expense amount to calculate a surplus; and

(j) determining, by the computer system, shared savings based at least in part on the surplus.

13. The computer system of claim 11, wherein the step of setting the targeted medical expense amount comprises:

determining, by the computer system, one or more of a maximum claims liability and an expected claims amount; and

adjusting, by the computer system, the targeted medical expense amount for the plan period based at least in part on the one or more of a maximum claims liability and an expected claims amount.

14. The computer system of claim 11, wherein the computer instructions further carry out the step of collecting the utilization data in real time during the plan period.

15. The computer system of claim 11, wherein the computer instructions further carry out the steps of:

during the plan period, collecting, by the computer system, the claims data;

at each time in one or more points during the plan period, calculating, by the computer system, an expected claims value for the plan period based at least in part on the subtotal of the claims data collected to date;

calculating, by the computer system, a projected value of shared savings by comparing the expected claims value with the targeted medical expense amount; and

adjusting, by the computer system, the healthcare provider discount rate based at least in part on the projected value of shared savings.