Data processing: financial – business practice – management – or co – Automated electrical financial or business practice or... – Insurance
Reexamination Certificate
2002-03-25
2009-11-17
O'Connor, Gerald J. (Department: 3686)
Data processing: financial, business practice, management, or co
Automated electrical financial or business practice or...
Insurance
C705S002000, C705S003000
Reexamination Certificate
active
07620560
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.
REFERENCES:
patent: 4667292 (1987-05-01), Mohlenbrock et al.
patent: 5018067 (1991-05-01), Mohlenbrock et al.
patent: 5099424 (1992-03-01), Schneiderman
patent: 5225976 (1993-07-01), Tawil
patent: 5253164 (1993-10-01), Holloway et al.
patent: 5301105 (1994-04-01), Cummings, Jr.
patent: 5307262 (1994-04-01), Ertel
patent: 5324077 (1994-06-01), Kessler et al.
patent: 5325293 (1994-06-01), Dorne
patent: 5365425 (1994-11-01), Torma et al.
patent: 5557514 (1996-09-01), Seare et al.
patent: 5835897 (1998-11-01), Dang
patent: 5970463 (1999-10-01), Cave et al.
patent: 6223164 (2001-04-01), Seare et al.
“Pattern-of-treatment differences among primary care physicians in alternative systems of care.” Cave, Douglas G. Benefits Quarterly. Brookfield: Third Quarter 1994. vol. 10, Iss.3; p. 6.
Article; “Advanced Profiling System Takes Center Stage in Capital Area Profiling Dispute,”Medical Utilization Management, vol. 22 (14), Jul. 21, 1994, 7 pages, Dialog Accession No. 02452667/9.
Article; “New Episode-Building Software is a Hit in Provider Profiling Field,”Medical Utilization Management, Nov. 24, 1994, 2 pages, Dialog Accession No. 02593104/9.
Article; “GMIS' Profiling System Pinpoints Total Costs,” by Faulkner & Gray,Medical Utilization Report, vol. 22 (17), Sep. 8, 1994, 6 pages, Dialog Accession No. 02520110/9.
Article; “Aetna Life Insurance Co.'s Health Information Consulting, Oxford Health Plans Select Symmetry's ETGs,”PR Newswire, Nov. 11, 1994, 2 pages, Dialog Accession No. 01966995/9.
Collins, Linda J., Managed Care May Improve Quality, Scrutiny Identifies Best Providers,Business Insurance, Feb. 19, 1990, 3 pages.
Gray, Michael; “Appraising Managed Healthcare's Quality,”ManagedCare, Summer, 1991, 4 pages.
Description; Peer-A-Med®,HealthChex, Inc., Aug. 1993 (revised), 7 pages.
Smith, Norman C. et al.; “Establishing Fair Profiling System in a Managed Care Environment,”Healthwise, Nov. 1994, 4 pages.
Weiner, Jonathan P., Dr. Ph., et al.; “Development and Application of a Population-Oriented Measure of Ambulatory Care Case-Mix,”Medical Care, vol. 29 (5), May 1991, pp. 452-473.
Presentation; “Aetna: Provider Insight™ Presentation,”AETNA, Aug. 3, 1994.
Averill, Richard F., M.S. et al.; “Design and Evaluation of a Prospective Payment System for Ambulatory Care,”3M Health Information Systems, Dec. 31, 1990.
Report; “Health Management Reports, Value Profiler,”Value Health Sciences, Inc., date unknown.
Boyer, Nancy; “Case Mix Adjustment Using Claims Information to Drill Down Provider Profiling,”HealthChex, Inc., date unknown, 14 pages.
Stankaitis, Joseph, M.D., MPH; “Peer-A-Med: Physician Practice Profiling,”HealthChex, Inc., date unknown, 35 pages.
Schneeweiss, Cherkin R. et al.; “An Updated ICD-90-CM Diagnosis Clusters Roster Based on NAMCS 1980 and 1981 for All Ambulatory Office-Based Specialities: Cross Tabulated with the International Classification of Health Problems in Primary Care (ICHPPC-2),”J. Fam Pract., vol. 22, 1986, pp. 69-72.
Schneeweiss, Ronald, MB, et al.; “Diagnosis Clusters Adapted for ICD-9-CM and ICHPPC-2,”The Journal of Family Practice, vol. 22 (1), 1986, p. 69-72.
Hibbard, Heddy, R.N., M.P.H., et al.; “Conference Proceedings, Primary Care Research: Theory an Methods,”U.S. Department of Health and Human Services, Sep. 1991, pp. 75-81.
Mainous, et al.; “Antibiotics for Colds in Children who are the High Prescribers?”,American Journal of Diseases of Children, Apr. 1998.
Hornbrook, Mark C.; “Health Care Episode: Definition, Measurement and Use,”Medical Care Review, vol. 42 (2), pp. 163-218, Fall 1985.
Moscovice, Ira; “A Method for Analyzing Resource Use in Ambulatory Care Settings,”Medical Care, vol. XV (12), Dec. 1977.
Kessler, Larry G. et al.; “Episodes of Psychiatric Utilization”,Medical Care, vol. XVIII (12), Dec. 1980.
Salkever, David S.; “Episode-Based Efficiency Comparison for Physicians and Nurse Practitioners”,Medical Care, vol. XX (2), Feb. 1982.
Garnick, Deborah W.; “Services and Charges by PPO Physicians for PPO and Indemnity Patients,”Medical Care, vol. 28 (10), Oct. 1990.
Brochure; “Course of Outpatient Treatment,” Medstat, Inc., date unknown.
Hornbrook, M.C.; “Definition and Measurement of Episodes of Care in Clinical and Economic Studies,”Cost Analysis for Clinical Practice Guidelines Conference Proceedings, Grady, M.L., Weis, K.A., eds., USDHHS, PHS, AHCPR, AHCPR Publication 95-0001, Rockville, Maryland, pp. 15-40 (1995).
Dorsey & Whitney LLP
Ingenix Inc.
Le Michelle
Luedke Adriana S.
O'Connor Gerald J.
LandOfFree
Computer-implemented method for grouping medical claims with... does not yet have a rating. At this time, there are no reviews or comments for this patent.
If you have personal experience with Computer-implemented method for grouping medical claims with..., we encourage you to share that experience with our LandOfFree.com community. Your opinion is very important and Computer-implemented method for grouping medical claims with... will most certainly appreciate the feedback.
Profile ID: LFUS-PAI-O-4111223