Identifying referral patterns between healthcare entities based on billed claims

Abstract

Identifying and quantifying referral patterns between healthcare entities based on billed claims. A method includes determining a plurality of billed claims and identifying one or more unique performing healthcare entities included in at least one of the plurality of billed claims. The method includes identifying one or more unique referring identifiers included in at least one of the plurality of billed claims. The method includes, for at least one of the one or more unique performing healthcare entities, calculating a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims.

What is claimed is: 
     
         1 . A method comprising:
 determining a plurality of billed claims;   identifying one or more unique performing healthcare entities included in at least one of the plurality of billed claims;   identifying one or more unique referring identifiers included in at least one of the plurality of billed claims;   for at least one of the one or more unique performing healthcare entities, calculating a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims.   
     
     
         2 . The method of  claim 1 , wherein the one or more unique performing healthcare entities comprises a healthcare practitioner, and wherein the one or more unique referring identifiers comprises one or more of a practitioner identifier, a clinic identifier, or a facility identifier. 
     
     
         3 . The method of  claim 2 , wherein identifying the healthcare practitioner of the one or more unique performing healthcare entities comprises identifying based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner, wherein the individual NPI is included in at least one of the plurality of billed claims. 
     
     
         4 . The method of  claim 2 , further comprising one or more of:
 for each of the one or more unique referring identifiers comprising a unique practitioner identifier, identifying a healthcare group and/or healthcare system associated with the unique practitioner identifier;   for each of the one or more unique referring identifiers comprising a unique clinic identifier, identifying a healthcare group associated with the unique clinic identifier; or   for each of the one or more unique referring identifiers comprising a unique facility identifier, identifying a healthcare system associated with the unique facility identifier.   
     
     
         5 . The method of  claim 4 , wherein one or more of:
 identifying the healthcare group and/or the healthcare system associated with the unique practitioner identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique practitioner identifier;   identifying the healthcare group associated with the unique clinic identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique clinic identifier; or   identifying the healthcare system associated with the unique facility identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique facility identifier.   
     
     
         6 . The method of  claim 1 , wherein the one or more unique performing healthcare entities comprises one or more of:
 a healthcare practitioner identified based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner and included in at least one of the plurality of billed claims;   a healthcare clinic identified based on an organization NPI associated with the healthcare clinic and included in at least one of the plurality of billed claims; or   a healthcare facility identified based on a Centers for Medicare and Medicaid Services Certification Number (CCN) associated with the healthcare facility and included in at least one of the plurality of billed claims.   
     
     
         7 . The method of  claim 1 , wherein the plurality of billed claims comprises carrier claims billed by a certain healthcare practitioner over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare practitioner, and wherein the method further comprises:
 calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by a certain referring practitioner of the one or more unique referring identifiers;   rolling the certain referring practitioner up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:
 a healthcare clinic; 
 a healthcare facility; 
 a healthcare group; or 
 a healthcare system; and 
   calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by the hierarchal healthcare entity.   
     
     
         8 . The method of  claim 1 , wherein the plurality of billed claims comprises facility claims billed by a certain healthcare facility over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare facility, and wherein the method further comprises:
 calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by a certain referring identifier of the one or more unique referring identifiers;   rolling the certain referring identifier up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:
 a healthcare clinic; 
 a healthcare facility; 
 a healthcare group; or 
 a healthcare system; and 
   calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by the hierarchal healthcare entity.   
     
     
         9 . The method of  claim 1 , wherein:
 identifying the one or more unique performing healthcare entities comprises identifying a plurality of performing healthcare practitioners on a single billed claim;   identifying the one or more unique referring identifiers comprises identifying a certain referring identifier on the single billed claim; and   the method further comprises proportioning the certain referring identifier among the plurality of performing healthcare practitioners on the single billed claim such that the certain referring identifier is calculated as referring only a portion of the single billed claim for each of the plurality of performing healthcare practitioners.   
     
     
         10 . The method of  claim 1 , further comprising, for at least one of the one or more unique referring identifiers, calculating a proportion of referrals going to each of the one or more unique performing healthcare entities over the plurality of billed claims. 
     
     
         11 . A system comprising one or more processors for executing instructions stored in non-transitory computer readable storage media, the instructions comprising:
 determining a plurality of billed claims;   identifying one or more unique performing healthcare entities included in at least one of the plurality of billed claims;   identifying one or more unique referring identifiers included in at least one of the plurality of billed claims;   for at least one of the one or more unique performing healthcare entities, calculating a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims.   
     
     
         12 . The system of  claim 11 , wherein the one or more unique performing healthcare entities comprises a healthcare practitioner, and wherein the one or more unique referring identifiers comprises one or more of a practitioner identifier, a clinic identifier, or a facility identifier. 
     
     
         13 . The system of  claim 12 , wherein the instructions are such that identifying the healthcare practitioner of the one or more unique performing healthcare entities comprises identifying based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner, wherein the individual NPI is included in at least one of the plurality of billed claims. 
     
     
         14 . The system of  claim 12 , wherein the instructions further comprise one or more of:
 for each of the one or more unique referring identifiers comprising a unique practitioner identifier, identifying a healthcare group and/or healthcare system associated with the unique practitioner identifier;   for each of the one or more unique referring identifiers comprising a unique clinic identifier, identifying a healthcare group associated with the unique clinic identifier; or   for each of the one or more unique referring identifiers comprising a unique facility identifier, identifying a healthcare system associated with the unique facility identifier.   
     
     
         15 . The system of  claim 14 , wherein the instructions further comprise one or more of:
 identifying the healthcare group and/or the healthcare system associated with the unique practitioner identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique practitioner identifier;   identifying the healthcare group associated with the unique clinic identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique clinic identifier; or   identifying the healthcare system associated with the unique facility identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique facility identifier.   
     
     
         16 . The system of  claim 11 , wherein the one or more unique performing healthcare entities comprises one or more of:
 a healthcare practitioner identified based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner and included in at least one of the plurality of billed claims;   a healthcare clinic identified based on an organization NPI associated with the healthcare clinic and included in at least one of the plurality of billed claims; or   a healthcare facility identified based on a Centers for Medicare and Medicaid Services Certification Number (CCN) associated with the healthcare facility and included in at least one of the plurality of billed claims.   
     
     
         17 . The system of  claim 11 , wherein the plurality of billed claims comprises carrier claims billed by a certain healthcare practitioner over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare practitioner, and wherein the instructions further comprise:
 calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by a certain referring practitioner of the one or more unique referring identifiers;   rolling the certain referring practitioner up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:
 a healthcare clinic; 
 a healthcare facility; 
 a healthcare group; or 
 a healthcare system; and 
   calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by the hierarchal healthcare entity.   
     
     
         18 . The system of  claim 11 , wherein the plurality of billed claims comprises facility claims billed by a certain healthcare facility over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare facility, and wherein the instructions further comprise:
 calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by a certain referring identifier of the one or more unique referring identifiers;   rolling the certain referring identifier up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:
 a healthcare clinic; 
 a healthcare facility; 
 a healthcare group; or 
 a healthcare system; and 
   calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by the hierarchal healthcare entity.   
     
     
         19 . The system of  claim 11 , wherein:
 identifying the one or more unique performing healthcare entities comprises identifying a plurality of performing healthcare practitioners on a single billed claim;   identifying the one or more unique referring identifiers comprises identifying a certain referring identifier on the single billed claim; and   the instructions further comprise proportioning the certain referring identifier among the plurality of performing healthcare practitioners on the single billed claim such that the certain referring identifier is calculated as referring only a portion of the single billed claim for each of the plurality of performing healthcare practitioners.   
     
     
         20 . The system of  claim 11 , wherein the instructions further comprise, for at least one of the one or more unique referring identifiers, calculating a proportion of referrals going to each of the one or more unique performing healthcare entities over the plurality of billed claims. 
     
     
         21 . Non-transitory computer readable storage media storing instructions for execution by one or more processors, the instructions comprising:
 determining a plurality of billed claims;   identifying one or more unique performing healthcare entities included in at least one of the plurality of billed claims;   identifying one or more unique referring identifiers included in at least one of the plurality of billed claims;   for at least one of the one or more unique performing healthcare entities, calculating a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims.   
     
     
         22 . The non-transitory computer readable storage media of  claim 21 , wherein the one or more unique performing healthcare entities comprises a healthcare practitioner, and wherein the one or more unique referring identifiers comprises one or more of a practitioner identifier, a clinic identifier, or a facility identifier. 
     
     
         23 . The non-transitory computer readable storage media of  claim 22 , wherein the instructions are such that identifying the healthcare practitioner of the one or more unique performing healthcare entities comprises identifying based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner, wherein the individual NPI is included in at least one of the plurality of billed claims. 
     
     
         24 . The non-transitory computer readable storage media of  claim 22 , wherein the instructions further comprise one or more of:
 for each of the one or more unique referring identifiers comprising a unique practitioner identifier, identifying a healthcare group and/or healthcare system associated with the unique practitioner identifier;   for each of the one or more unique referring identifiers comprising a unique clinic identifier, identifying a healthcare group associated with the unique clinic identifier; or   for each of the one or more unique referring identifiers comprising a unique facility identifier, identifying a healthcare system associated with the unique facility identifier.   
     
     
         25 . The non-transitory computer readable storage media of  claim 24 , wherein the instructions further comprise one or more of:
 identifying the healthcare group and/or the healthcare system associated with the unique practitioner identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique practitioner identifier;   identifying the healthcare group associated with the unique clinic identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique clinic identifier; or   identifying the healthcare system associated with the unique facility identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique facility identifier.   
     
     
         26 . The non-transitory computer readable storage media of  claim 21 , wherein the one or more unique performing healthcare entities comprises one or more of:
 a healthcare practitioner identified based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner and included in at least one of the plurality of billed claims;   a healthcare clinic identified based on an organization NPI associated with the healthcare clinic and included in at least one of the plurality of billed claims; or   a healthcare facility identified based on a Centers for Medicare and Medicaid Services Certification Number (CCN) associated with the healthcare facility and included in at least one of the plurality of billed claims.   
     
     
         27 . The non-transitory computer readable storage media of  claim 21 , wherein the plurality of billed claims comprises carrier claims billed by a certain healthcare practitioner over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare practitioner, and wherein the instructions further comprise:
 calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by a certain referring practitioner of the one or more unique referring identifiers;   rolling the certain referring practitioner up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:
 a healthcare clinic; 
 a healthcare facility; 
 a healthcare group; or 
 a healthcare system; and 
   calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by the hierarchal healthcare entity.   
     
     
         28 . The non-transitory computer readable storage media of  claim 21 , wherein the plurality of billed claims comprises facility claims billed by a certain healthcare facility over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare facility, and wherein the instructions further comprise:
 calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by a certain referring identifier of the one or more unique referring identifiers;   rolling the certain referring identifier up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:
 a healthcare clinic; 
 a healthcare facility; 
 a healthcare group; or 
 a healthcare system; and 
   calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by the hierarchal healthcare entity.   
     
     
         29 . The non-transitory computer readable storage media of  claim 21 , wherein:
 identifying the one or more unique performing healthcare entities comprises identifying a plurality of performing healthcare practitioners on a single billed claim;   identifying the one or more unique referring identifiers comprises identifying a certain referring identifier on the single billed claim; and   the instructions further comprise proportioning the certain referring identifier among the plurality of performing healthcare practitioners on the single billed claim such that the certain referring identifier is calculated as referring only a portion of the single billed claim for each of the plurality of performing healthcare practitioners.   
     
     
         30 . The non-transitory computer readable storage media of  claim 21 , wherein the instructions further comprise, for at least one of the one or more unique referring identifiers, calculating a proportion of referrals going to each of the one or more unique performing healthcare entities over the plurality of billed claims.