Best possible payment expected for healthcare services

Abstract

A system is disclosed that is useful by hospitals and other healthcare providers for automatically determining the best possible or maximum amount of payments a healthcare provider can lawfully expect to receive for healthcare resources which takes into account various discounts agreed upon by the healthcare provider with various private insurance companies as well as public (i.e., government) insurance providers, which administer managed healthcare plans including Medicare and Medicaid, all payments received against expected payments and a yield measurement approach for determining the providers performance at a given point in time and across various segments of its operations. In accordance with one aspect of the present invention, contracts between a healthcare provider and all private insurance companies and public insurance providers may be modeled. Various data including healthcare resources provided to patients up to a given point in time, applicable insurance company, and healthcare resource code are entered into the system. The system is able to calculate the best possible revenue that the healthcare provider can lawfully expect to receive taking into account the various discounts negotiated with the various insurance companies. Indeed, once the data is loaded, the system can provide an accurate snapshot of a healthcare provider's best possible expected revenues at any given time based upon services rendered instead of waiting until the healthcare resources have been billed out to insurance companies, patients, and third party payers. It can also provide an accurate snapshot of all payments received against those expected payments to determine yield across various segments of its operations.

1 . A method for calculating the best possible revenue a healthcare provider can lawfully expect at a given time, the method comprising the steps:
 (a) modeling one or more contracts a healthcare provider may have with the terms of payment for various payers;   (b) modeling payment terms for patients without health insurance;   (c) providing patient data;   (d) providing raw total charge data; and   (e) calculating the best possible revenue as a function of patient data, raw total charge data as well as the contract model data.   
     
     
         2 . The method as recited in  claim 1 , further including the step of dividing actual payments by the best possible revenue to determine the yield in terms of best possible revenue. 
     
     
         3 . The method as recited in  claim 2 , further including the step of determining the yield for individual payers. 
     
     
         4 . The method as recited in  claim 2 , further including the step of receiving profitability data and determining the profitability of a healthcare provider on a patient level. 
     
     
         5 . The method as recited in  claim 2 , further including the step of determining the yield for individual service lines. 
     
     
         6 . The method as recited in  claim 2 , further including the step of determining the yield for individual patient types. 
     
     
         7 . The method as recited in  claim 2 , further including the step of determining the yield for individual facilities.