Episode treatment groups of correlated medical claims

Abstract

A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

1 - 3 . (canceled)  
   
   
       4 . The episode treatment grouping according to  claim 11 , wherein the anchor record further comprises one of a management record and a surgery record.  
   
   
       5 . The episode treatment grouping according to  claim 4 , wherein the management record further comprises at least one medical claim data representing services of a medical care provider engaged in direct evaluation, management or treatment of a patient.  
   
   
       6 . The episode treatment grouping according to  claim 4 , wherein the surgery record further comprises at least one medical claim data representing surgical procedures, performed by a medical care provider.  
   
   
       7 . The episode treatment grouping according to  claim 11 , wherein the ancillary record further comprises at least one medical claim data representing medical care services which are incidental to the direct evaluation, management and treatment of a medical patient.  
   
   
       8 . The episode treatment grouping according to  claim 11 , wherein the facility record represents medical claim data for use of a medical care facility.  
   
   
       9 . The episode treatment grouping according to  claim 11 , wherein the drug record further comprises medical claim data representing pharmaceutical prescriptions.  
   
   
       10 . A computer-implemented episode treatment grouping of medical claims, the medical claims each including at least one of a diagnosis code and a treatment code, generated by: 
 storing a plurality of episode treatment groups, wherein each episode treatment group is associated with one or more diagnosis codes or treatment codes;    obtaining medical claims for a patient, wherein the medical claims each include at least one diagnosis code or treatment code;    constructing from the patient's medical claims an episode treatment group comprising a first cluster of episode-related medical claim data based upon the diagnosis code or treatment code in the patient's medical claims, the first episode treatment group containing an anchor record and representing a first medical episode;    constructing from the patient's medical claims a second cluster of episode-related medical claim data based upon the diagnosis code or treatment code in the patient's medical claims; and    grouping the second cluster of episode-related medical claim data to the first episode treatment group based upon relationship of the second cluster to the first medical episode represented by the first episode treatment group.    
   
   
       11 . A computer-implemented episode treatment grouping of medical claims, generated by: 
 storing a plurality of episode treatment groups, wherein each episode treatment group is associated with one or more diagnosis codes or treatment codes and has an associated dynamic time window;    reading medical claim data records associated with one or more patients into a computer memory;    validating each of the medical claim data records for at least one of a diagnosis code and a treatment code;    reading at least one pre-defined relation between the at least one of the diagnosis code and the treatment code and one or more of the stored episode treatment groups; and    grouping the validated medical claim data records to at least one of the plurality of episode treatment groups based on the pre-defined relationship and the dynamic time window associated with each episode treatment group, each of the at least one of a plurality of episode treatment groups further comprising one anchor record and at least one data records linked thereto, the at least one data records being selected from the group consisting of ancillary records, facility records and prescription drug records.