System and Method For Implementing Program Compliance For Health-Based Rewards

Abstract

A compliance process provides the ability to identify members that have completed a required activity for a Health Incentive Program (HIP) by comparing standard data such as claims, pharmacy, laboratory, biometric, health risk assessment and other pertinent internal and external data (hereafter “source data”) against established compliance criteria for that type of data for the specific HIP. If the member meets all compliance criteria within the designated timeframe, the member's achievement is recorded, resulting in the appropriate reward being granted as defined by the HIP. The compliance process solution provides an automated way for a payer to evaluate internal and/or external data including claims, pharmacy and/or biometric data to identify instances of a member completing required activities.

1 . A process for determining compliance with a health incentive program comprising;
 receiving at a claim processing system medical claims for individuals associated with one or more medical reimbursement products;   filtering the medical claims in accordance with at least one of a group, class and medical reimbursement product to which a member is associated;   providing data from the medical claims in accordance with an associated medical reimbursement product;   receiving an indicator that the data is available for processing for compliance with one or more health incentive programs;   determining by a processor if one or more health incentive programs applies to the data in accordance with the associated medical reimbursement product;   applying by a conditional processing engine compliance rules for each of the one more health incentive programs to determine if one or more individuals associated with the data has attained one or more achievement levels;   if one or more individuals associated with the data has attained one or more achievement levels, confirming by the conditional processing engine, eligibility of the one or more individuals in the one more health incentive programs;   generating by the conditional processing engine one of a new achievement record or an update to an existing achievement record for each of the one or more individuals if the one or more individuals have attained one or more achievement levels; and   making the achievement records available for processing by a reward generation component.   
     
     
         2 . The process according to  claim 1 , further comprising determining by the reward generation component, the one or more individual's reward and applying the reward to the individual. 
     
     
         3 . The process according to  claim 2 , wherein applying the reward to the individual includes automatically reducing an amount owed by the individual under the individual's medical reimbursement product. 
     
     
         4 . The process according to  claim 3 , wherein the automatic reduction is selected from a reduction in co-insurance and a reduction in co-payment. 
     
     
         5 . The process according to  claim 1 , wherein the one or more achievement levels are associated with at least one of: an individual attaining a biometric goal; an individual member completing a health assessment; an individual member obtaining a medical test; and an individual member completing a course of medical treatment. 
     
     
         6 . The process according to  claim 1 , further comprising filtering the medical claims data to determine claim date information prior to determining if one or more health incentive programs applies; wherein the claim date information is utilized to determine at least one of if one or more health incentive programs applies and if one or more individuals associated with the member health-related data has attained one or more achievement levels. 
     
     
         7 . The process according to  claim 1 , wherein providing data from the medical claims in accordance with an associated medical reimbursement product includes populating by the processor a staging table with the data.