System and method for intelligent management of medical care

Abstract

A computerized medical care system provides validation of a diagnosis of a medical condition and requested medical services for treating the medical condition. The medial care system invokes multiple filters to determine the appropriateness of the diagnosis and medical service. Real time feedback is provided based on the determination. If the medical care cannot be validated, the feedback includes the reasons for the failure to validate, and any supporting materials for the lack of validation. The feedback may also prompt the requesting entity to provide additional information to help support the medical provider's position as to why the requested medical care is appropriate.

1 . In a computerized medical care system, a method for providing a medical pre-approval, the method comprising:
 receiving from a requesting device a medical code associated with a medical determination;   identifying one or more filters enabled for the computerized medical care system;   applying the identified one or more filters for the received medical code;   determining validity of the medical determination based on the applied one or more filters; and   providing feedback to the requesting device based on the determination of the validity of the medical determination, wherein the feedback prompts modification of the medical determination that is ultimately rendered to a patient if the medical determination is not validated.   
     
     
         2 . The method of  claim 1 , wherein the medical code is a diagnosis code, the medical determination is diagnosis of a medical condition, and the one or more filters includes a medical diagnosis filter, wherein the feedback is configured to prompt modification of the diagnosis that is ultimately rendered to the patient if the diagnosis is not validated. 
     
     
         3 . The method of  claim 2 , wherein the applying of the medical diagnosis filter and the determining of the validity of the diagnosis includes:
 displaying a question that should be considered in making the diagnosis of the medical condition;   prompting a user response to the displayed question;   receiving the user response to the displayed question;   comparing an expected response to the displayed question with the received user response; and   validating the diagnosis if the expected response matches the received user response.   
     
     
         4 . The method of  claim 2  further comprising:
 adding to a historical database information on the validity of the diagnosis code in association with a medical provider providing the diagnosis code; 
 calculating based on information in the historical database a ratio of collected diagnosis codes that have not been validated to collected diagnosis codes that have been validated; and 
 generating a report based on the ratio information. 
 
     
     
         5 . The method of  claim 1 , wherein the feedback is a letter including information on the validity of the diagnosis, wherein the letter is generated in real time with the validating of the diagnosis. 
     
     
         6 . The method of  claim 1 , wherein the medical code is a service code, the medical determination is a medical service determined based on a diagnosed medical condition, and the filters include a plurality of medical procedure filters, wherein the feedback is configured to prompt modification of the medical service that is ultimately rendered to the patient if the medical service is not validated. 
     
     
         7 . The method of  claim 6 , wherein each of the plurality of medical procedure filters are applied one by one in sequence. 
     
     
         8 . The method of  claim 6  further comprising:
 providing a graphical user interface with a list of the plurality of medical procedure filters; 
 receiving a user selection of desired ones of the plurality of medical procedure filters; and 
 enabling each selected medical procedure filter for applying in making the validity determination of the determined medical service. 
 
     
     
         9 . The method of  claim 6 , wherein the applying of at least one of the plurality of medical procedure filters includes:
 analyzing historical data collected in association with the service code from a historical database;   determining based on the analyzed historical data whether the medical service is statistically reasonable; and   returning a result of applying the at least one of the plurality of medical procedure filters based on the determination.   
     
     
         10 . The method of  claim 9  further comprising:
 adding to the historical database information on the medical service determined for the medical condition. 
 
     
     
         11 . The method of  claim 6 , wherein at least one of the plurality of medical procedure filters is a heat filter, and the applying of the heat filter includes:
 identifying a date of injury;   identifying a timing of the medical service, wherein the medical service is a heat-based therapy;   determining whether the timing of the heat-based therapy is appropriate relative to the date of injury; and   returning a result of applying the heat filter based on the determination.   
     
     
         12 . The method of  claim 6 , wherein at least one of the plurality of medical procedure filters is a rarity filter, and the applying of the rarity filter includes:
 retrieving historical data of medical services provided for the diagnosed medical condition;   identifying a rate in which the determined medical service was provided for the identified diagnosis based on the retrieved historical data;   identifying a threshold rate;   determining whether the identified rate satisfies the threshold rate; and   returning a result of applying the rarity filter based on the determination.   
     
     
         13 . The method of  claim 6 , wherein at least one of the plurality of medical procedure filters is a utilization filter, and the applying of the utilization filter includes:
 receiving information on a requested number of visits or duration of care for the identified service code;   analyzing historical data of previous number of visits or durations of care provided for the diagnosed medical condition;   identifying a threshold number of visits or durations of care based on the analyzed historical data;   determining whether the requested number of visits or duration of care satisfies the threshold number of visits or duration of care; and   returning a result of applying the utilization filter based on the determination.   
     
     
         14 . The method of  claim 6 , wherein at least one of the plurality of medical procedure filters is a level of service filter, and the applying of the level of service filter includes:
 identifying a level of service associated with the identified service code;   analyzing historical data of previous levels of service provided for the diagnosed medical condition;   identifying a threshold level of service based on the analyzed historical data;   determining whether the identified level of service satisfies the threshold level of service; and   returning a result of applying the level of service filter based on the determination.   
     
     
         15 . The method of  claim 6 , wherein at least one of the plurality of medical procedure filters is a billing guidelines filter, and the applying of the billing guidelines filter includes:
 receiving a requested charge amount for the determined medical service;   identifying a billing guideline associated with the determined medical service;   determining whether the requested charge amount satisfies the identified billing guideline; and   returning a result of applying the billing guidelines filter based on the determination.   
     
     
         16 . The method of  claim 6 , wherein at least one of the plurality of medical procedure filters is a charges filter, and the applying of the charges filter includes:
 receiving a requested charge amount for the determined medical service;   analyzing historical data of previous charges associated with the diagnosed medical condition;   identifying a threshold charge amount based on the analyzed historical data;   determining whether the identified charge amount satisfies the threshold charge amount; and   returning a result of applying the charges filter based on the determination.   
     
     
         17 . The method of  claim 6 , wherein the feedback is a letter including information on the validity of the medical service, wherein the letter is generated in real time with the validating of the determined medical service. 
     
     
         18 . The method of  claim 6 , wherein the applying of at least one of the plurality of medical procedure filters includes:
 identifying a specific patient for which the medical service is determined;   retrieving historical data of medical care provided to the specific patient;   determining based on the retrieved historical data whether the determined medical service is appropriate for the specific patient; and   returning a result of applying the at least one of the plurality of medical procedure filters based on the determination.   
     
     
         19 . A computerized medical care system for providing a medical pre-approval, the system comprising:
 a processor; and   a memory operably coupled to the processor and storing program instructions therein, the processor being operable to execute the program instructions, the program instructions including:
 receiving from a requesting device a medical code associated with a medical determination; 
 identifying one or more filters enabled for the computerized medical care system; 
 applying the identified one or more filters for the received medical code; 
 determining validity of the medical determination based on the applied one or more filters; and 
 providing feedback to the requesting device based on the determination of the validity of the medical determination, wherein the feedback prompts modification of the medical determination that is ultimately rendered to a patient if the medical determination is not validated. 
   
     
     
         20 . A computerized medical care system for providing a medical pre-approval, the system comprising:
 a computing engine configured to receive a diagnosis code identifying diagnosis of a medical condition and a service code identifying a requested medical service;   a medical diagnosis filter coupled to the engine and configured to display a question that should be considered in making the diagnosis of the medical condition, the medical diagnosis filter further being configured to prompt a user response to the displayed question, validate the diagnosis if the expected response matches the user response, and invalidate the diagnosis if the expected response fails to match the user response; and   a plurality of medical procedure filters coupled to the engine and configured to determine a validity of the requested medical service relative to the diagnosis based on each of the applied medical procedure filters,   wherein the computing engine is configured to provide feedback based on the determination of the validity of the diagnosis and requested medical service, wherein the feedback prompts modification of the diagnosis or medical service that is ultimately rendered to a patient if respectively the diagnosis or requested medical service is not validated.