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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
First Claim
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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.

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