Cluster of correlated medical claims in an episode treatment group

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 - 2 . (canceled)  
   
   
       3 . A computer-implemented process for profiling medical claim data including: 
 (a) 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;    (b) reading medical claim data records associated with one or more patients into a computer memory;    (c) validating each of the medical claim data records for at least one of a diagnosis code and a treatment code;    (d) 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    (e) 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 record linked thereto, the at least one data records being selected from the group consisting of ancillary records, facility records and prescription drug records.    
   
   
       4 . The process as claimed in  claim 3 , wherein each of the at least one of a plurality of episode treatment groups contain at least one cluster of medical claim data records.  
   
   
       5 . The process as claimed in  claim 4 , wherein the at least one cluster further comprises at least one ancillary record and at least one anchor record.  
   
   
       6 . The process as claimed in  claim 3 , wherein the step (e) further comprises differentiating patient severity based upon data relating to at least one of patient age, complicating conditions, co-morbidities and major surgeries.  
   
   
       7 . The process as claimed in  claim 3 , further comprising outputting and discontinuing processing of invalid data records.  
   
   
       8 . The process as claimed in  claim 7  wherein outputting and discontinuing processing of invalid data records includes assigning a different episode treatment group to a medical claim data record containing at least one of an invalid diagnosis code, an invalid treatment code and an invalid provider type.  
   
   
       9 . The process as claimed in  claim 3 , further comprising the step of identifying valid episode treatment groups by comparing current treatment codes to prior related episodes in look-up tables.  
   
   
       10 . The process as claimed in  claim 3 , further comprising the step of flagging valid claim records with a diagnosis code identifier.  
   
   
       11 . The process as claimed in  claim 10 , wherein the step of flagging valid claim records comprises the step of incrementing a sequential anchor count and a sequential episode count for each episode treatment group assignment.  
   
   
       12 . The process as claimed in  claim 3 , further comprising resetting the dynamic time window of the medical episode when a second medical claim data records matches an open medical episode, the dynamic time window being reset for an additional period of time until no other data records are grouped to the open medical episode within the reset dynamic time window.  
   
   
       13 . The process as claimed in  claim 12 , wherein the step of resetting the dynamic time window of the medical episode, further comprises the step of selecting a most recent claim record if more than one matched claim record exists.  
   
   
       14 . The process as claimed in  claim 3 , wherein a medical claim data record is shifted to a different one of the plurality of episode treatment groups upon receipt of a second medical claim record containing changes in patient condition comprising at least one of comorbidity, complication and defining surgery.  
   
   
       15 . The process as claimed in  claim 3 , wherein a medical claim data record originally assigned to a first episode treatment group based upon a first diagnosis in the medical claim record is shifted to a second episode treatment group based on at least one of a second, third and fourth diagnosis in the medical claim data record.  
   
   
       16 . The process as claimed in  claim 9 , wherein the step of identifying valid episode treatment groups further comprises the step of comparing pharmaceutical claim data in a patient's medical claim data to open episode treatment groups for the patient by analyzing Generic Drug Codes by episode treatment group and National Drug Code by Generic Drug Codes look-up tables.  
   
   
       17 . The process as claimed in  claim 3 , further comprising the step of identifying medical providers treating episodes treatment groups by identifying each episode treatment group by Primary Care Physician.