Systems and methods for assessing and optimizing healthcare administration

Abstract

A comprehensive patient data assessment system and method for use in generating, tracking and analyzing medical data related to healthcare administered by a group of physicians to a specified patient population. The system is operative to track data related to the claims history, case management, pharmacy data, and lab tests / results for each patient treated by each patient's primary care physician preferably through electronic medical records that are accessible over a computer network. The system is operative to generate data indicative of the utilization of healthcare resources utilized to treat each patient within the patient population, as well as ensure that each primary care physician utilizes appropriate codes for each diagnosis and procedure / test administered to each patient. The system further provides for categorization of patients afflicted with chronic conditions that require high-cost care. The systems are exceptionally effective in conserving medical resources, ensuring uniformity in administering healthcare, and achieving optimal patient outcomes.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS[0001]The present application is a continuation application of U.S. patent application Ser. No. 11 / 063,268, entitled SYSTEMS AND METHODS FOR ASSESSING AND OPTIMIZING HEALTHCARE ADMINISTRATION, filed Feb. 22, 2005, the teachings of which are incorporated herein by reference.STATEMENT RE: FEDERALLY SPONSORED RESEARCH / DEVELOPMENT[0002]Not ApplicableBACKGROUND OF THE INVENTION[0003]The present invention is directed to systems and methods for comprehensively assessing and optimizing the administration of healthcare as rendered by a group of physicians to a specific patient population. More particularly, the present invention comprises systems and methods that conserve medical resources utilized to care for the patient population, ensure uniformity in the procedures / tests utilized to render such care, identify and assess those patients afflicted with a chronic condition requiring high-cost healthcare, and provide means to continuously monitor and eva...

AI Technical Summary

Benefits of technology

[0015]With regard to those patients that have been properly identified as being afflicted with a high-cost chronic condition, the system of the present invention is operative to separately compile data related thereto to thus enable those patients to be assessed based upon the type of condition and required long-term treatment necessary to secure the most favorable patient outcome. Additionally, such information associated with those members having a high-cost chronic condition can be utilized to develop cost-effective treatment strategies that may be custom tailored to provide an optimal patient treatment.

[0016]In addition to the foregoing, it is further contemplated that by virtue of existing preferably in an electronic medical record format, the systems and methods of the present invention will be exceptionally useful in performing standardized electronic transactions as provided for in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. In this regard, such transactions, as set forth in HIPAA, expressly include claims, remittance and payment advice, claims status, enrollment and disenrollment in a health plan, premium payments, eligibility inquiries and responses, referral certifications and authorizations, coordination of benefits, and the like, all of which can be facilitated through use of the present invention according to a standardized transaction format, which can include the uniform use of codes typically associated with conventional billing practices, such as diagnosis codes mentioned above (i.e., ICDM-9-CM, CPT-4, NDC, and HCPCS).

Problems solved by technology

Along these lines, it is contemplated that a number of statistical analyses can be applied in reviewing the electronic medical records that are operative to assess potentially inappropriate coding practices, which are thus indicative of wasteful, unnecessary or sub-optimal healthcare.

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