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

1. A computer implemented method for estimating financial liability of a patient for a medical service to be provided to the patient by a medical service provider, said method comprising:

utilizing a computer processor to perform the following steps:

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 the 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;

determining if the second data set includes a first set of specific historical payments that the medical service provider of the patient has been paid by the healthcare coverage entity of the patient for medical services provided to the population of individuals that are similar to the medical service for the patient;

if the second data set includes the first set of specific historical payments, estimating the expected payment associated with the medical service for the patient based on the first set of specific historical payments;

if the second data set does not include the first set of specific historical payments, estimating the expected payment associated with the medical service for the patient based on a second set of specific historical payments that medical service providers sharing a similar classification as the medical service provider of the patient have been paid by the healthcare coverage entity of the patient for medical services provided to the population of individuals that are similar to the medical service for the patient;

further 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 estimated cost expected to be borne by the patient for incurring the medical service, and an indicator of reliability of that estimated cost.

2. The method of claim 1 , 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.

3. The method of claim 1 , wherein the second of data set is based on adjudicated medical claims.

4. The method of claim 1 , wherein the set of 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.

5. The method of claim 1 , 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.

6. The method of claim 1 further comprises the computer processor performing the following step:

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.

7. The method of claim 6 , wherein estimating the expected payment associated with the medical service for the patient based on the historical payments further comprises the computer processor performing the following step:

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.

8. The method of claim 1 , wherein the indicator of reliability indicates the source of the data used to determine the expected payment.

9. A system for estimating financial liability of a patient for a medical service to be provided to the patient by a medical service provider, said system comprising:

a computer system;

program code on a non-transitory computer-readable medium, which when executed on the computer system causes the computer system to:

access 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;

determine if the first data set includes a specific established payment that a medical service provider of the 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, return 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, electronically access 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;

determine if the second data set includes a first set of specific historical payments that the medical service provider of the patient has been paid by the healthcare coverage entity of the patient for medical services provided to the population of individuals that are similar to the medical service for the patient;

if the second data set includes the first set of specific historical payments, estimate the expected payment associated with the medical service for the patient based on the first set of specific historical payments;

if the second data set does not include the first set of specific historical payments, estimate the expected payment associated with the medical service for the patient based on a second set of specific historical payments that medical service providers sharing a similar classification as the medical service provider of the patient have been paid by the healthcare coverage entity of the patient for medical services provided to the population of individuals that are similar to the medical service for the patient;

further estimate 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

present financial information that communicates the estimated cost expected to be borne by the patient for incurring the medical service, and an indicator of reliability of that estimated cost.

10. The system of claim 9 , further comprising an output device, wherein the computer system presents financial information through the output device.

11. The system of claim 9 , wherein the population of individuals and the patient have a same healthcare coverage entity at the time each was provided the medical service.

12. The system of claim 11 , wherein the healthcare coverage entity 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.

13. The system of claim 9 , wherein the similarity of the 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.

14. The system of claim 9 , wherein the second data set is based on adjudicated medical claims.

15. The system of claim 14 , wherein the adjudicated medical claims are for payments for medical services incurred by individuals having a same healthcare coverage entity as the patient.

16. The system of claim 15 , wherein the adjudicated medical claims are for payments for medical services provided to the individuals by the same medical service provider providing the medical service to the patient.

17. The system of claim 9 , wherein the set of 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.

18. The system of claim 9 , wherein the medical service includes more than one medical procedure and wherein the computer system estimates the expected payment based on expected payments associated with the more than one medical procedure and wherein the computer system estimates the cost expected to be borne by the patient based on the expected payments associated with the more than one medical procedure.

19. The system of claim 9 , wherein the indicator of reliability indicates the source of the data used to determine the expected payment.