Automated Emergency Department Visit Level Verification System

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Solution Overview

Problem

The existing healthcare claim coding systems, particularly for emergency department visit levels, suffer from inconsistencies and overcoding due to flexible guidelines, leading to inaccurate compensation and increased costs for payers like insurance companies and CMS, which are difficult to verify manually in a timely and reliable manner.

Innovation Solution

A computer-implemented method and apparatus that derive an expected emergency department visit level (EEDVL) by extracting treatment codes, calculating a standard value, extended value, and patient complexity adjustment, and determining the EEDVL using a threshold table, to accurately reflect the resource usage and intensity of patient treatment, thereby providing a standardized and automated verification process.

Engineering Contradictions & Design Principles

VSEngineering Contradiction Analysis

1Ease of operation

If flexible E/M coding guidelines are used to allow provider discretion in coding, then ease of operation is improved, but manufacturing precision deteriorates due to inconsistent and overcoded claims

Engineering Contradiction:

Improveease of codingVSAvoidcoding accuracy

Core Design Contradiction:

Ease of operationVSManufacturing precision

Solution Approach 1:

The system changes the parameters used for coding from flexible provider discretion to objective, standardized parameters including treatment codes, resource utilization codes, patient complexity factors, and time-based metrics. This transformation converts subjective coding into an automated calculation based on measurable parameters, resolving the contradiction between ease of operation and coding accuracy.

Inventive Principle:

Principle #35Parameter changes

Solution Approach 2:

The patent replaces the manual, provider-based mechanical coding process with an automated computerized system that calculates visit levels using standardized algorithms. This substitution eliminates human variability and discretion, ensuring consistent and accurate coding while maintaining ease of operation through automation.

Inventive Principle:

Principle #28Mechanics substitution (Replace mechanical system)

2Measurement precision

If manual examination of claims is used to verify coding accuracy, then measurement precision is improved, but productivity deteriorates due to large capital and labor requirements

Engineering Contradiction:

Improveverification accuracyVSAvoidclaims processing speed

Core Design Contradiction:

Measurement precisionVSProductivity

Solution Approach 1:

The system replaces manual claim examination with an automated computerized verification process that uses standardized algorithms to calculate expected visit levels and compare them against submitted codes. This substitution maintains high verification accuracy while dramatically improving productivity by eliminating the need for large numbers of human reviewers.

Inventive Principle:

Principle #28Mechanics substitution (Replace mechanical system)

Solution Approach 2:

The verification system performs self-service by automatically comparing submitted visit level codes against independently calculated expected levels based on treatment and resource data. This self-verification mechanism eliminates the need for external manual review while maintaining measurement precision.

Inventive Principle:

Principle #25Self-service

3Reliability

If human staff are used to evaluate claims, then reliability is improved through expert judgment, but productivity deteriorates due to inability to evaluate every claim in near real time

Engineering Contradiction:

Improveevaluation reliabilityVSAvoidclaims evaluation speed

Core Design Contradiction:

ReliabilityVSProductivity

Solution Approach 1:

The patent replaces human staff evaluation with an automated computerized system that applies standardized coding guidelines and algorithms to determine expected visit levels. This substitution maintains reliability through consistent application of objective criteria while achieving near real-time processing capability that human staff cannot match.

Inventive Principle:

Principle #28Mechanics substitution (Replace mechanical system)

4Manufacturing precision

If standardized coding guidelines are implemented to reduce overcoding, then manufacturing precision is improved, but device complexity increases due to multiple treatment codes and calculation steps

Engineering Contradiction:

Improvecoding consistencyVSAvoidsystem complexity

Core Design Contradiction:

Manufacturing precisionVSDevice complexity

Solution Approach 1:

The system achieves coding consistency through a universal standardized algorithm that processes all claims using the same objective criteria. The multi-functional algorithm can handle various treatment codes, resource utilization codes, and patient complexity factors through a single integrated verification process, managing complexity while maintaining precision.

Inventive Principle:

Principle #6Universality (Multi-functionality)

Data Source

PatentUS11289205B1Methods, apparatuses, and systems for deriving an expected emergency department visit level

Publication Date: 2022.03.29 OPTUM INC

AI summary

Computer program products, methods, systems, apparatus, and computing entities for deriving an expected emergency department visit level are described. In one example embodiment, an example computing device receives a set of healthcare claims representing a patient's visit to an emergency department and extracts a set of treatment codes from the set of healthcare claims. The treatment codes represent services performed during the emergency department visit and the condition of the patient. The example computing device also derives a standard value, an extended value, and a patient complexity adjustment using the set of treatment codes and determines the expected emergency department visit level using the standard value, the extended value, and the patient complexity adjustment.