Episode-of-Care Referral Analytics for Cost-Transparent Specialist Matching
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Solution Overview
Problem
Existing referral systems lack real-time database updates, cost transparency, and customization for payer-specific authorization criteria, and do not integrate telemedicine or provide instantaneous scheduling and medication management.
Innovation Solution
A system and method that includes a mobile application for healthcare providers, utilizing predictive analytics to recommend specialists based on patient-specific costs, quality, and travel distance, with real-time database updates, telemedicine integration, and instantaneous scheduling, and medication management.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Loss of information
If traditional referral systems are used, then referral management is simple, but real-time database updates and cost transparency are lacking
Solution Approach 1:
The patent introduces a referral management system as an intermediary between providers, payers, and patients. This system acts as a mediator that centralizes database updates, cost calculations, and authorization workflows, thereby providing real-time cost transparency and information access without requiring direct integration between all parties, thus managing complexity through a dedicated intermediary platform
Solution Approach 2:
The patent replaces traditional manual referral management processes with an automated electronic system. Instead of paper-based workflows and manual database updates, the system uses automated digital processes, electronic databases, and real-time data exchange mechanisms to provide instantaneous cost transparency and update propagation across all stakeholders
2Adaptability or versatility
If referral systems lack customization, then system operation is simple, but payer-specific authorization criteria cannot be accommodated
Solution Approach 1:
The patent implements dynamic authorization criteria that can be customized for different payers. The system allows authorization rules, cost structures, and referral requirements to be dynamically configured and updated based on specific payer contracts and policies, enabling the system to adapt to varying payer requirements without requiring separate systems for each payer
Solution Approach 2:
The patent segments the authorization criteria into payer-specific modules or configurations. Each payer can have their own customized authorization rules, cost parameters, and referral requirements stored and managed separately within the unified system, allowing simultaneous support for multiple payer-specific criteria while maintaining a single integrated platform
3Productivity
If referral systems do not integrate telemedicine, then system complexity is low, but referral efficiency and patient access are limited
Solution Approach 1:
The patent merges telemedicine capabilities directly into the referral management system. By combining traditional referral functions with telemedicine services (video consultations, remote monitoring, electronic prescribing) within a single integrated platform, the system enables seamless referral workflows that can include remote patient evaluations and immediate specialist access, thereby improving referral efficiency while consolidating functionality rather than adding separate systems
4Loss of time
If instantaneous scheduling is not provided, then system complexity is low, but patient wait times and referral completion time increase
Solution Approach 1:
The patent implements preliminary scheduling actions by pre-configuring provider availability, appointment slots, and scheduling rules within the system. The automated scheduling engine uses pre-established parameters to instantly generate and confirm appointments when referrals are submitted, eliminating manual scheduling delays while the complexity is managed through automated rule-based scheduling rather than complex real-time coordination
Data Source
AI summary
A method of using data markers in a health insurance entity claims database to assist in tracking episodes of care (EOCs) to assist in generating referrals of medical specialists to a referring user, comprises providing an interface enabling a referring user to request a medical procedure for a patient and for making a referral of a medical specialist to assist with the medical procedure; identifying medical specialists; accessing a health insurance entity claims database storing historical claims associated with the same medical procedure; evaluating the historical claims to retrospectively estimate historical EOCs; using a respective data marker in the health insurance entity claims database to uniquely mark each retrospectively estimated historical EOC; using predictive analytics to generate an expected EOC for each medical specialist; generating an expected cost and a list of candidate medical specialists therefrom; receiving a selection; generating and using a particular data marker to mark an actual claim for the particular medical procedure and actual claims for the actual subsequent medical events to track the actual EOC in the health insurance entity claims database.