Health care payment system utilizing an intensity adjustment factor applied to provider episodes of care

• US 5,819,228 A
• Filed: 10/31/1995
• Issued: 10/06/1998
• Est. Priority Date: 10/31/1995
• Status: Expired due to Term

• Current Assignee: UtiliMed, Inc.
• Original Assignee: UtiliMed, Inc.
• Inventors: Spiro, Alan
• Primary Examiner(s): Hudspeth, David R.
• Assistant Examiner(s): Thomas, Joseph
• Application Number:
  US08/550,744
• Time in Patent Office: 1,071 Days
• Field of Search: 395/201, 395/202, 395/203, 395/204, 395/230, 395/232, 395/234, 395/235, 395/238, 395/240, 395/239, 705/1, 705/2, 705/3, 705/4, 705/30, 705/32, 705/34, 705/35, 705/38, 705/39, 705/40, 283/59, 283/900, 346/33 ME, 128/630, 128/920
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method for providing a payment mechanism for out-patient diagnostic imaging services based upon an episode of care payment methodology. An episode of care is selected as a given time period during which all imaging studies performed for a given patient for one clinical indication. An episode of care may include multiple diagnostic imaging procedures. All tests performed by a provider within the given time period comprise one episode of care. An intensity adjustment factor based upon the types of imaging studies performed is multiplied against the total episodes of care. This results in a total intensity adjusted episode of care. Each provider'"'"'s percentage of the total intensity adjusted episode of care is calculated, and each provider is paid from the funds collected from the members. Provisions are also made for giving credit to providers based upon the complexity of the imaging studies. Furthermore, providers can be given credit for consulting with the referring physician to provide the best imaging studies based upon the identified clinical conditions.

Claims

1. A computer implemented method of providing payments to diagnostic imaging providers of a health care plan comprising the steps of:

funding a diagnostic imaging provider account through a fixed per member per first-time period dollar amount;

crediting a provider with an episode of care which includes all imaging studies performed on a given member within a second time period for one clinical indication;

calculating an intensity adjustment factor for the provider based upon the types of imaging studies performed;

totaling the provider'"'"'s episodes of care during the first time period;

calculating intensity adjusted episodes of care for the providers by indexing the totaled episodes of care by the intensity adjustment factor;

totaling the intensity adjusted episodes of care for all providers during the first time period;

calculating the provider'"'"'s percentage of the total of all providers'"'"' intensity adjusted episodes of care for the first time period;

storing an amount representing the provider'"'"'s percentage of the total of all providers'"'"' intensity adjusted episodes of care times the amount funded in the diagnostic imaging account in the first time period and

paying the provider from the diagnostic imaging provider account the stored amount.

2. The method of claim 1 and the further step of assigning Relative Value Units to each type of imaging study.

3. The method of claim 2 wherein the intensity adjustment factor is derived by dividing the total number of Relative Value Units associated with all imaging studies performed during the first time period by the total number of imaging studies actually performed in the first time period.

4. The method of claim 3 wherein the time period during which the diagnostic imaging provider account is funded is based on a monthly dollar amount.

5. The method of claim 4 wherein the second time period for an episode of care is sixty days.

6. The method of claim 1 wherein the first and second time periods are the same.

7. The method of claim 1 wherein each provider is paid monthly from the diagnostic imaging provider account.

8. The method of claim 1 and the further step of creating additional accounts to pay non-diagnostic imaging providers without impacting payments to diagnostic imaging providers.

9. The method of claim 1 and the further step of crediting the provider with an imaging study for consulting with a referring physician regarding the requested diagnostic imaging study.

10. The method of claim 1 and the further step of crediting the provider with an episode of care for consulting with a referring physician regarding the requested diagnostic imaging study.

11. A computer implemented method of providing payments based on specific diseases to health care providers of a health care plan comprising the steps of:

funding a disease specific provider account through a fixed per member per first-time period dollar amount;

crediting a provider with an episode of care which includes all diagnostic studies performed on a given member within a second time period for a specific disease;

calculating an intensity adjustment factor for the provider based upon the types of studies performed;

totaling the provider'"'"'s episodes of care for all providers during the first time period;

calculating an intensity adjusted episode of care of the providers by indexing the totaled episodes of care by the intensity adjustment factor;

totaling the intensity adjusted episodes of care for all providers during the first time period;

calculating the provider'"'"'s percentage of the total of all providers'"'"' intensity adjusted episodes of care for the first time period;

storing an amount representing the provider'"'"'s percentage of the total of all providers intensity adjusted episodes of care times the amount funded in the disease specific provider account in the first time period and

paying the provider from the disease specific provider account the stored amount.

12. The method of claim 11 and the further step of assigning relative value units to each type of diagnostic study.

13. The method of claim 12 wherein the intensity adjustment factor is derived by dividing the total number of Relative Value Units associated with all diagnostic studies performed during the first time period by the total number of diagnostic studies actually performed in the first time period.

14. The method of claim 13 wherein the time period during which the disease specific provider account is funded is based on a monthly dollar amount.

15. The method of claim 13 wherein the second time period for an episode of care is sixty days.

16. The method of claim 11 wherein the first and second time periods are the same.

17. The method of claim 11 wherein each provider is paid monthly from the disease specific provider account.

18. The method of claim 11 and the further step of creating additional accounts to pay non-disease specific providers without impacting payments to disease specific providers.

19. The method of claim 11 and the further step of crediting the provider with a diagnostic study for consulting with a referring physician regarding the requested diagnostic study.

20. The method of claim 11 and the further step of crediting the provider with an episode of care for consulting with a referring physician regarding the requested diagnostic study.

21. A computer implemented method of providing payments to diagnostic imaging providers of a health care plan comprising the steps of:

funding a diagnostic imaging provider account through a fixed per member per first-time period dollar amount;

crediting a provider with an episode of care which includes all imaging studies performed on a given member within a second time period for one clinical indication;

assigning a Relative Value Unit to each imaging study;

calculating the average Relative Value Unites per imaging study;

totaling the provider'"'"'s episodes of care during the first time period;

calculating an intensity adjusted episode of care for the providers by indexing the totaled episodes of care for the providers by the average Relative Value Units per imaging study;

totaling the intensity adjusted episodes of care for all providers during the first time period;

calculating the provider'"'"'s percentage of the total of all providers'"'"' intensity adjusted episodes of care for the first time period;

storing an amount representing the provider'"'"'s percentage of the total of all providers'"'"' intensity adjusted episodes of care times the amount funded in the diagnostic imaging account in the first time period and

paying the provider from the diagnostic imaging provider account the stored amount.

22. The method of claim 21 wherein the time period during which the diagnostic imaging provider account is funded is based on a monthly dollar amount.

23. The method of claim 22 wherein the second time period for an episode of care is sixty days.

24. The method of claim 21 wherein the first and second time periods are the same.

25. The method of claim 21 wherein each provider is paid monthly from the diagnostic imaging provider account.

26. The method of claim 21 and the further step of creating additional accounts to pay non-diagnostic imaging providers without impacting payments to diagnostic imaging providers.

27. The method of claim 21 and the further step of crediting the provider with an imaging study for consulting with a referring physician regarding the requested diagnostic imaging study.

28. The method of claim 21 and the further step of crediting the provider with an episode of care for consulting with a referring physician regarding the requested diagnostic imaging study.