Provider Evaluation System for Claimant Direction
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Solution Overview
Problem
Current methods for managing healthcare costs through provider networks are limited in optimizing efficiency and reducing costs at the claim level, as they do not control the number of medical procedures performed per claimant, leading to high overall claim costs.
Innovation Solution
A system and method that evaluates medical service providers and directs claimants to specific providers based on provider scores, grouping claimants into control, decision, and redirect groups to optimize medical procedures and costs, without requiring provider networks or service discounts, by using a database to store and analyze provider and claimant information.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Loss of energy
If provider networks with fixed rates or standardized discounts are used to control medical service costs, then cost per procedure type is reduced, but the number of medical procedures performed per claimant is not controlled leading to high overall claim costs
Solution Approach 1:
The patent changes the evaluation parameters from fixed network rates to dynamic provider scores based on multiple performance metrics including utilization rates, quality measures, and efficiency indicators. This allows the system to select providers who optimize both cost per procedure and overall claim cost through their performance on these parameters.
Solution Approach 2:
The patent implements a feedback mechanism where provider scores are continuously updated based on their performance in managing claimants. Providers receive feedback on their utilization rates, quality metrics, and cost effectiveness, allowing them to adjust their practices to improve both cost per procedure and overall claim cost outcomes.
2Productivity
If claimants are directed to specific medical service providers based on provider scores, then efficiency of care and cost at the claim level are optimized, but the system complexity increases due to provider scoring and claimant direction mechanisms
Solution Approach 1:
The patent introduces an intermediary claims administrator system that manages the complexity of provider scoring and claimant direction. This intermediary handles the evaluation, scoring, and redirection processes, shielding both providers and claimants from the underlying system complexity while enabling optimized care coordination.
Solution Approach 2:
The patent uses parameter changes to simplify the interface between the complex scoring system and users. Provider scores are calculated using multiple parameters but presented as simple rankings or recommendations to claims administrators, reducing the perceived complexity while maintaining the analytical depth needed for optimization.
3Ease of manufacture
If provider networks are used to control medical service costs, then standardized discounts apply to given types of medical service, but utilization is not controlled leading to steep overall claim costs
Solution Approach 1:
The patent transitions from standardized network discounts to dynamic provider scoring that incorporates utilization metrics as a key parameter. This allows the system to reward providers who effectively control utilization while maintaining quality, replacing the static discount structure with a performance-based evaluation system.
Solution Approach 2:
The patent implements feedback loops that monitor and report utilization patterns to both claims administrators and providers. This feedback enables real-time adjustments in claimant direction to providers with better utilization control, creating a system that actively manages utilization rather than relying on static network agreements.
Data Source
AI summary
A method and system for evaluating medical service providers, and before or after an initial medical service provider visit by a claimant, determining whether to direct that claimant on subsequent medical service provider visits to a different medical service provider to optimize efficiency of care and minimize cost at the claim level.