Computer-implemented method for profiling medical claims
DC CAFCFirst Claim
1. A computer-implemented process for processing medical claims including the steps of:
- (a) reading a medical claim data, input as at least one of a plurality of data records, into a computer memory;
(b) validating each of the at least one of a plurality of data records for at least one of a diagnosis code and a treatment code;
(c) reading at least one pre-defined relationship between the at least one of a diagnosis code and a treatment code in the validated at least one of a plurality of data records and pre-defined episode treatment categories; and
(d) grouping the validated at least one of a plurality of data records to an episode treatment category based upon the pre-defined relationship, each episode treatment category having a dynamic time window defining a time period during which validated at least one of plurality of data records may be grouped to an episode treatment category.
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Abstract
A computer-implemented program for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The software program allows an objective means for measuring and quantifying health, care services. An episode treatment group (ETG) is a patient classification system with groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. ETG grouper software uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.
343 Citations
52 Claims
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1. A computer-implemented process for processing medical claims including the steps of:
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(a) reading a medical claim data, input as at least one of a plurality of data records, into a computer memory; (b) validating each of the at least one of a plurality of data records for at least one of a diagnosis code and a treatment code; (c) reading at least one pre-defined relationship between the at least one of a diagnosis code and a treatment code in the validated at least one of a plurality of data records and pre-defined episode treatment categories; and (d) grouping the validated at least one of a plurality of data records to an episode treatment category based upon the pre-defined relationship, each episode treatment category having a dynamic time window defining a time period during which validated at least one of plurality of data records may be grouped to an episode treatment category. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32)
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33. A computer-implemented process for processing medical claims including the steps of:
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(a) reading a first patient'"'"'s medical claim data, input as at least one of a plurality of data records, into a computer memory; (b) validating each of the at least one of a plurality of data records for at least one of a diagnosis code and a treatment code; (c) reading at least one pre-defined relation between the at least one of a diagnosis code and a treatment code in the validated at least one of a plurality of data records and pre-defined medical episodes; and (d) grouping the validated at least one of a plurality of data records to at least one of a plurality of episode treatment groups, each of the at least one of a plurality of episode treatment groups further comprising an episode treatment group identifier, a most recent anchor from date of treatment and a most recent sequential anchor record count. - View Dependent Claims (34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52)
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Specification