Method and system for estimating the financial liability of a patient for a medical service

Abstract

A computer implemented method involving a medical service for a patient includes estimating an expected payment associated with the medical service for the patient based on a set of data including payments for similar medical services provided to a population of individuals. The method also includes estimating a cost expected to be borne by the patient for incurring the medical service based on the estimated expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient. The method further includes presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service.

What is claimed is: 
     
         1 . A computer implemented method, comprising:
 accessing a first data set including established payments that medical service providers have agreed to be paid by healthcare coverage entities for providing medical services to individuals;   determining if the first data set includes a specific established payment that a medical service provider of a patient has agreed to be paid by a healthcare coverage entity of the patient for a medical service provided to the patient;   if the first data set includes the specific established payment, returning the specific established payment for the medical service as an expected payment associated with the medical service;   if the first data set does not include the specific established payment, accessing a second data set including historical payments made by healthcare coverage entities to medical service providers for medical services provided to a population of individuals;   estimating the expected payment associated with the medical service for the patient based on the historical payments;   estimating a cost expected to be borne by the patient for incurring the medical service based on the expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient; and   presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service.   
     
     
         2 . A system comprising:
 a computer system;   program code on a computer-readable medium, which when executed on the computer system performs functions including:
 estimating an expected payment associated with a medical service for a patient based on a set of data including payments for similar medical services provided to a population of individuals; 
 estimating a cost expected to be borne by the patient for incurring the medical service based on the estimated expected payment and based on a set of parameters associated with a healthcare coverage plan of the patient; and 
 presenting financial information that communicates the cost expected to be borne by the patient for incurring the medical service. 
   
     
     
         3 . A computer implemented method for estimating financial liability of a patient for a medical service to be provided to said patient by a medical service provider, said method comprising:
 in a computer system, determining if a first source of data is available that includes a specific established payment that a healthcare coverage entity has previously agreed to pay to the medical service provider for providing the medical service to the patient;   if the computer system determines that a first source of data including the specific established payment is available, returning the specific established payment for the medical service as an expected payment associated with the medical service;   if the computer system determines that a first source of data including the specific established payment is not available, as an alternative:
 accessing a second source of data including historical payments actually made by one or more healthcare coverage entities to said medical service provider for providing the medical service; and 
 in the computer system, estimating the expected payment associated with the medical service for the patient based on the historical payments rather than on any specific established payments from the first data source; 
   in the computer system, estimating a cost expected to be borne by the patient for incurring the medical service based on the expected payment and based on a set of one or more parameters associated with a healthcare coverage plan of the patient; and   presenting financial information that communicates the estimated cost expected to be borne by the patient for incurring the medical service and an indicator of the reliability of that estimated cost.   
     
     
         4 . The method of  claim 3 , wherein the second source of data includes a first data set and a second data set, wherein the first data set includes historical payments made by the healthcare coverage entity to the medical service provider for providing the medical service and the second data set includes historical payments made by the healthcare coverage entity to a plurality of medical service providers for providing the medical service, wherein said plurality of medical service providers includes medical service providers in addition to the first-mentioned medical service provider, and wherein estimating the expected payment associated with the medical service for the patient based on the historical payments comprises:
 determining whether the first data set includes a statistically significant set of data for determining the expected payment associated with the medical service for the patient; and   if the first data set includes a statistically significant set of data, determining the expected payment associated with the medical service for the patient from the data in the first data set.   
     
     
         5 . The method of  claim 3 , wherein estimating the expected payment associated with the medical service for the patient based on the historical payments further comprises:
 if the first data set does not include a statistically significant set of data, determining the expected payment associated with the medical service for the patient from the data in the second data set for the plurality of service providers.   
     
     
         6 . The method of  claim 3 , wherein estimating the expected payment associated with the medical service for the patient based on the historical payments further comprises:
 if the first data set does not include a statistically significant set of data, determining if any of the plurality of medical service providers of the second data set have a similar classification to that of the first mentioned service provider; and   if the plurality of medical service providers includes medical service providers having a similar classification to that of the first mentioned service provider, determining the expected payment associated with the medical service for the patient from the data in the second data set for the plurality of service providers that have a similar classification to that of the first mentioned service provider.   
     
     
         7 . The method of  claim 3 , wherein the similarity of classification is based on at least one of a geographic location of the medical service providers, a specialty of the medical service providers, and a type of facility of the medical service providers. 
     
     
         8 . The method of  claim 3 , wherein the healthcare coverage entity of the patient is at least one of a commercial insurer, a government insurer, a third party administrator, an employer, an employer group, a pharmaceutical benefits manager, and a health maintenance organization. 
     
     
         9 . The method of  claim 3 , wherein the second source of data is based on adjudicated medical claims. 
     
     
         10 . The method of  claim 3 , wherein the set of one or more parameters associated with the healthcare coverage plan of the patient includes at least one of a co-pay amount, a co-insurance value, a deductible threshold, a lifetime benefits maximum payout value, a patient out-of-pocket total maximum amount, and a healthcare payer total benefits payment amount. 
     
     
         11 . The method of  claim 3 , wherein the medical service for the patient includes more than one medical procedure and wherein at least one of the returning the specific established payment or the estimating the expected payment includes determining expected payments associated with the more than one medical procedure and wherein estimating the cost expected to be borne by the patient is based on the expected payments associated with the more than one medical procedure. 
     
     
         12 . The method of  claim 3 , wherein the indicator of reliability indicates the source of the data used to determine the expected payment.