Best possible payment expected for healthcare services
View Patent ↗A system is disclosed that is useful by hospitals and other healthcare providers for automatically determining the best possible or maximum amount of payments a healthcare provider can lawfully expect to receive for healthcare resources which takes into account various discounts agreed upon by the healthcare provider with various private insurance companies as well as public (i.e., government) insurance providers, which administer managed healthcare plans including Medicare and Medicaid, all payments received against expected payments and a yield measurement approach for determining the providers performance at a given point in time and across various segments of its operations. In accordance with one aspect of the present invention, contracts between a healthcare provider and all private insurance companies and public insurance providers may be modeled. Various data including healthcare resources provided to patients up to a given point in time, applicable insurance company, and healthcare resource code are entered into the system. The system is able to calculate the best possible revenue that the healthcare provider can lawfully expect to receive taking into account the various discounts negotiated with the various insurance companies. Indeed, once the data is loaded, the system can provide an accurate snapshot of a healthcare provider's best possible expected revenues at any given time based upon services rendered instead of waiting until the healthcare resources have been billed out to insurance companies, patients, and third party payers. It can also provide an accurate snapshot of all payments received against those expected payments to determine yield across various segments of its operations.
1. A computerized method for calculating by way of a computerized processing engine under program control the best possible revenue a healthcare provider can lawfully expect at a given time ,the method comprising the steps:
(a) storing on a computer readable medium a plurality of contracts between a healthcare provider and a corresponding plurality of third party payers, each of which contracts identifies the amounts of payment that the corresponding third party payer will pay to the health care provider for medical services and supplies provided by said health care provider to patients covered by said corresponding third party payer;
(b) storing on said computer readable medium patient data which (i) identifies the patients who have received the medical services and supplies provided by the health care provider, and (ii) identifies any of said plurality of third party payers which are obligated to pay at least a portion of medical expenses incurred by said patients who have received the medical services and supplies provided by the health care provider;
(c) storing on said computer readable medium patient data which identifies the medical services and supplies provided by said health care provider to said patients who have received the medical services and supplies provided by the health care provider, to define raw charge data;
(d) storing on said computer readable medium payments made to said health care provider by (i) said any of said plurality of third party payers which is obligated to pay at least a portion of medical expenses incurred by said patients who have received the medical services and supplies provided by the health care provider, and (ii) said patients who have received medical services and supplies provided by said health care provider; and
(e) calculating, under program control by way of the computerized processing engine, the amounts of payment due to the health care provider at the given time by executing the following steps under program control:
(i) determining whether any of the raw charge data incurred by said patients who have received medical services and supplies provided by said health care provider will at least be partially paid by said any of said plurality of third party payers which are obligated to pay at least a portion of medical expenses incurred by said patients who have received the medical services and supplies provided by the health care provider, by determining if said patients who have received the medical services and supplies provided by the health care provider are covered by at least one third party payer that has a contract with said health care provider;
(ii) for patients who have received medical services and supplies, and for which at least a portion of said raw charge data are covered by the at least one third party payer that has a contract with said health care provider as determined in step (i), transforming said raw charge data to fees provided by the contract between said health care provider and said at least one third party payer, to define transformed fees; and
(iii) calculating the amounts of payment due to said health care provider at the given time by summing raw charge data of patients not covered by a third party provider and said transformed fees and subtracting payments made by (i) said any of said plurality of third party payers which are obligated to pay at least a portion of medical expenses incurred by said patients who have received the medical services and supplies provided by the health care provider and (ii) said patients who have received medical services and supplies, to provide data representative of the total amounts of payment due and owing to said health care provider at the given time.
2. The computerized method as recited in claim 1 , further including the step of dividing under program control payments received as determined in step (d) by data representative of said total amounts of payment due under program control to determine the yield in terms of said total amounts of payment due.
3. The computerized method as recited in claim 2 , further including the step of determining under program control the yield for individual third party payers.
4. The computerized method as recited in claim 2 , further including the step of determining under program control the profitability on a patient level based upon said yield data by analyzing the yield for one or more categories of medical services.
5. The computerized method as recited in claim 2 , further including the step of determining under program control the yield for patients covered by third party payers and patients not covered by third party payers.
6. The computerized method as recited in claim 2 , further including the step of determining under program control the yield for individual facilities of a health care provider.