Computer-implemented method for profiling medical claims

• US 6,370,511 B1
• Filed: 11/09/1998
• Issued: 04/09/2002
• Est. Priority Date: 06/22/1995
• Status: Expired due to Term

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Symmetry Health Data Systems Incorporated (UnitedHealth Group Incorporated)
• Inventors: Dang, Dennis K.
• Primary Examiner(s): Poinvil, Frantzy
• Application Number:
  US09/188,986
• Time in Patent Office: 1,247 Days
• Field of Search: 705/2, 705/3, 707/10, 707/100, 707/104
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology 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.

Claims

1. A computer-implemented method of grouping pharmaceutical claims data, comprising the steps of:

(a) reading pharmaceutical claims 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 a valid drug code;

(c) reading at least one pre-defined relationship between the valid drug 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 group based upon the pre-defined relationship read in step (c).

2. The method according to claim 1, wherein step (b) further comprises the step of reading at least one of a national drug code and a generic drug code from the at least one of a plurality of data records.

3. The method according to claim 1, wherein step (d) further comprises the steps of:

(a) providing a table comprising a listing of eligible episode treatment groups for all pharmaceutical drugs, the eligible episode treatment groups being ordered based upon a pre-determined likelihood that the pharmaceutical drug is prescribed for an eligible episode treatment group;

(b) reading the table of eligible episode treatment groups for the valid drug code read from step (b) of claim 1;

(c) comparing each eligible episode treatment group to an open episode treatment group for the patient, and

(d) grouping the medical claim record to the open episode treatment group based upon the comparison in step (c).

4. The method according to claim 1, further comprising the steps of:

(a) constructing a first cluster of episode-related medical claim data, the cluster having one anchor record;

(b) grouping a second cluster of episode-related medical claim data to the first cluster of episode-related medical claim data based upon relationship of the second cluster to the medical episode represented by the first cluster; and

(c) shifting the second cluster of episode-related medical claim data to a different and distinct episode group conditioned upon a higher degree of relationship of the second cluster to the different and distinct episode group.

5. The method according to claim 1, wherein step (d) further comprises the step of 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 one anchor record and n data records linked thereto, the n data records being selected from the group consisting of ancillary records, facility records and prescription drug records, where n is an integer greater than or equal to 0, and having a predefined time window during which the n data records may group to the one anchor record.

6. The method according to claim 5, wherein each of the at least one of a plurality of episode treatment groups contain at least one cluster.

7. The method according to claim 6, wherein the at least one cluster further comprises at least one ancillary record and at least one anchor record.

8. The method according to claim 1, wherein the step (d) further comprises the step of differentiating patient severity based upon data relating to at least one of patient age, complicating conditions, comorbidities and major surgeries.

9. The method according to claim 1, wherein step (d) further comprises the step of creating a cluster of at least one of a plurality of medical claim records grouped to a common anchor record in the episode treatment category.

10. The method according to claim 9, wherein the episode treatment category further comprises at least one of a plurality of clusters.

11. The method according to claim 1, wherein step (d) further comprises the step of grouping related medical claim data encoded as a plurality of machine readable bits on a machine readable carrier, comprising one anchor record and n data records linked thereto, the n data records being selected from the group consisting of ancillary records, facility records and prescription drug records, where n is an integer greater than or equal to 0.

12. The method according to claim 1, further comprising the following step (e):

shifting a grouping a medical claim data from a first episode treatment group to a second episode treatment group based upon occurrence of a different degree of relationship to the second episode treatment group than to the first episode treatment group.

13. The method according to claim 12, wherein the second episode treatment group is representative of medical claim data based upon at least one of a complication, co-morbidity, surgery and changed severity of the first episode treatment group.