Service Provider Network Composition via Performance Metrics
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Solution Overview
Problem
Insurance providers and employers face difficulties in determining the best service providers for workers' compensation, as existing methods lack effective criteria to assess and compare the quality of care provided by medical service providers, leading to inconsistent outcomes for injured workers.
Innovation Solution
A system utilizing a computer-readable storage medium, processor, and display device to analyze claim information, determine metric values for service providers based on factors like recovery time and patient satisfaction, assign scores, and generate results data to define a service provider network composition, ensuring only superior providers are included.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If traditional service provider selection methods are used, then network composition is simple to maintain, but quality of care and patient outcomes are inconsistent
Solution Approach 1:
The patent transforms the service provider selection process by changing evaluation parameters from simple credentials to multiple performance metrics including patient outcomes, satisfaction scores, and clinical effectiveness data. This enables reliable quality assessment through quantifiable parameters while the automated scoring system manages the complexity of evaluating multiple providers across numerous metrics.
Solution Approach 2:
The patent replaces manual provider selection and evaluation processes with an automated computer-based system that calculates performance scores using claim data, patient outcomes, and satisfaction metrics. This substitution of mechanical automation for manual assessment ensures consistent quality evaluation while the system manages the complexity of processing multiple data points across numerous providers.
2Measurement precision
If comprehensive metrics are used to evaluate service providers, then quality assessment accuracy improves, but data processing complexity increases
Solution Approach 1:
The patent achieves precise quality assessment by transforming multiple evaluation criteria into a unified performance score through parameter standardization. The system processes diverse data types including claim outcomes, patient satisfaction surveys, and clinical metrics by converting them into comparable standardized parameters that can be aggregated and ranked systematically.
Solution Approach 2:
The patent creates a universal evaluation framework that handles multiple types of service provider data through a single integrated scoring system. The computer-based platform universally processes various data sources including medical outcomes, patient feedback, and operational metrics, applying consistent calculation methods across all providers regardless of data type or source.
3Loss of time
If service provider networks are optimized for patient outcomes, then recovery time decreases, but network reevaluation frequency must increase
Solution Approach 1:
The patent implements continuous feedback loops where patient outcome data and satisfaction metrics are systematically collected and fed back into the performance scoring system. This feedback mechanism enables the network to identify and redirect patients to higher-performing providers based on real-time performance data, reducing recovery time while the automated system manages ongoing evaluations without requiring frequent manual network restructuring.
Solution Approach 2:
The patent creates a dynamic service provider network where provider performance scores are continuously updated based on incoming claim data and patient outcomes. The system adapts to changing provider performance automatically, allowing the network composition to evolve dynamically in response to performance changes while maintaining operational stability through automated score recalculation rather than frequent manual reviews.
Data Source
AI summary
A system and method are provided for determining a composition of a service provider network for providing services according to a workers' compensation insurance plan. The system and method acquires claim information, which describes workers' compensation claims and medical service providers, and determines a metric value for each of the medical service providers, adjusts the metric values, assigns scores based on the adjusted metric values, determines an average of the assigned scores, and generates results data based on the assigned scores. The results data indicates, for each of the medical service providers, whether the medical service provider should be included in the service provider network. The service provider metrics include a metric that relates to an amount paid per claim and a percentage of claims that involved lost time.