System and method for intelligent management of medical care
A computerized medical care system provides validation of a diagnosis of a medical condition and requested medical services for treating the medical condition. The medial care system invokes multiple filters to determine the appropriateness of the diagnosis and medical service. Real time feedback is provided based on the determination. If the medical care cannot be validated, the feedback includes the reasons for the failure to validate, and any supporting materials for the lack of validation. The feedback may also prompt the requesting entity to provide additional information to help support the medical provider's position as to why the requested medical care is appropriate.
1. A data processing apparatus adapted for providing medical pre-approval, the data processing apparatus comprising:
a processor; and
a memory coupled to the processor and having program instructions stored therein, the processor being operable to execute the program instructions, the program instructions including:
providing a first interface option for identifying a first code for a diagnosed condition;
providing a second interface option for identifying a second code for a proposed medical service for the diagnosed condition;
providing a third interface option for identifying a proposed charge amount for the proposed medical service;
receiving a request for medical pre-approval, the request including the first code for the diagnosed condition, the second code for the proposed medical service, and the proposed charge amount;
retrieving historical data of past charge amounts stored in a data store for the proposed medical service;
identifying a reasonableness value based on the historical data of past charge amounts, wherein the identified reasonableness value is configured to be traced to a specific past charge amount stored in the data store for a specific provider for the proposed medical service performed for a specific patient;
comparing the proposed charge amount against the identified reasonableness value;
determining whether the proposed charge amount is presumptively reasonable or unreasonable based on the comparison of the proposed charge amount against the identified reasonableness value;
if the proposed charge amount is determined to be presumptively reasonable based on the comparison, providing information indicative of pre-approval of the proposed medical service or charge; and
if the proposed charge amount is determined to be presumptively unreasonable based on the comparison, prompting submission of information justifying the proposed charge amount.
2. The data processing apparatus of claim 1 , wherein the program instructions further include:
updating the historical data of past charge amounts based on a charge amount submitted by a specific medical provider; and
identifying an updated reasonableness value based on the updated historical data.
3. The data processing apparatus of claim 1 , wherein the program instructions for identifying the reasonableness value further comprises program instructions for:
identifying a percentile distribution value; and
identifying a charge amount associated with the percentile distribution value.
4. The data processing apparatus of claim 3 , wherein the percentile distribution value is user selected, and the percentile distribution value selected by a first user differs from the percentile distribution value selected by a second user.
5. The data processing apparatus of claim 3 , wherein the program instructions further include:
updating the historical data of past charge amounts based on a charge amount submitted by a specific medical provider; and
identifying an updated charge amount based on the updated historical data.
6. The data processing apparatus of claim 3 , wherein the determining whether the proposed charge is presumptively reasonable or unreasonable based on the comparison includes:
comparing the proposed charge amount with the charge amount associated with the percentile distribution value;
determining that the proposed charge amount is presumptively reasonable if the charge amount is below the charge amount associated with the percentile distribution value; and
determining that the proposed charge amount is presumptively unreasonable if the charge amount is above the charge amount associated with the percentile distribution value.
7. The data processing apparatus of claim 1 , wherein the program instructions for providing information indicative of pre-approval of the proposed medical service or charge includes generating a notification of the pre-approval substantially in real-time with the receipt of the request for medical pre-approval.
8. The data processing apparatus of claim 7 , wherein the notification is an electronic notification configured to be displayed on a display screen.
9. The data processing apparatus of claim 1 , wherein the program instructions further include:
identifying a reasonable amount that will be paid to a medical provider if the proposed charge amount is determined to be presumptively unreasonable; and
transmitting the identified amount to the medical provider.
10. The data processing apparatus of claim 1 , wherein the program instructions further include:
providing a plurality of filters;
receiving actuation of one or more of the plurality of filters; and
determining whether the proposed charge amount is presumptively reasonable or unreasonable based on the actuated one or more filters.
11. The data processing apparatus of claim 10 , wherein the actuated one or more filters includes a billing guidelines filter, and the program instructions further include:
identifying a billing guideline associated with the proposed medical service;
determining that the proposed charge amount is presumptively reasonable if the proposed charge amount complies with the identified billing guideline; and
determining that the proposed charge amount is presumptively unreasonable if the proposed charge amount fails to comply with the identified billing guideline.
12. The data processing apparatus of claim 1 , wherein the program instructions further comprise:
determining that the proposed medical service is medically necessary and further determining that the proposed charge amount is presumptively unreasonable.
13. The data processing apparatus of claim 1 , wherein the program instructions further include:
correlating the historical data of past charge amounts to specific medical providers; and
generating a report based on the correlated historical data.
14. The data processing apparatus of claim 1 , wherein the past charge amounts are associated with a plurality of different medical providers submitting the charge amounts for a plurality of different patients.
15. A non-transitory computer readable media embodying program instructions for execution by a data processing apparatus, the program instructions adapting the data processing apparatus for providing medical pre-approval, the program instructions comprising:
providing a first interface option for identifying a first code for a diagnosed condition;
providing a second interface option for identifying a second code for a proposed medical service for the diagnosed condition;
providing a third interface option for identifying a proposed charge amount for the proposed medical service;
receiving a request for medical pre-approval, the request including the first code for the diagnosed condition, the second code for the proposed medical service, and the proposed charge amount;
retrieving historical data of past charge amounts stored in a data store for the proposed medical service;
identifying a reasonableness value based on the historical data of past charge amounts, wherein the identified reasonableness value is configured to be traced to a specific past charge amount stored in the data store for a specific provider for the proposed medical service performed for a specific patient;
comparing the proposed charge amount against the identified reasonableness value;
determining whether the proposed charge amount is presumptively reasonable or unreasonable based on the comparison of the proposed charge amount against the identified reasonableness value;
if the proposed charge amount is determined to be presumptively reasonable based on the comparison, providing information indicative of pre-approval of the proposed medical service or charge; and
if the proposed charge amount is determined to be presumptively unreasonable based on the comparison, prompting submission of information justifying the proposed charge amount.
16. The non-transitory computer readable media of claim 13 , wherein the program instructions for determining whether the proposed charge amount is presumptively reasonable or unreasonable based on the comparison includes program instructions for:
comparing the proposed charge amount with the charge amount associated with the percentile distribution value; and
determining that the proposed charge amount is presumptively reasonable if the charge amount is below the charge amount associated with the percentile distribution value; and
determining that the proposed charge amount is presumptively unreasonable if the charge amount is above the charge amount associated with the percentile distribution value.
17. The non-transitory computer readable media of claim 16 , wherein the percentile distribution value is user selected, and the threshold percentile distribution value selected by a first user differs from the percentile distribution value selected by a second user.
18. The non-transitory computer readable media of claim 15 , wherein the program instructions for providing information indicative of pre-approval of the proposed medical service or charge includes generating a notification of the pre-approval substantially in real-time with the receipt of the request for medical pre-approval.
19. The non-transitory computer readable media of claim 18 , wherein the notification is an electronic notification configured to be displayed on a display screen.
20. The non-transitory computer readable media of claim 15 , wherein the program instructions further include:
identifying a reasonable amount that will be paid to a medical provider if the proposed charge amount is determined to be presumptively unreasonable; and
transmitting the identified amount to the medical provider.
21. The non-transitory computer readable media of claim 15 , wherein the program instructions further include:
providing a plurality of filters;
receiving actuation of one or more of the plurality of filters; and
determining whether the proposed charge amount is presumptively reasonable or unreasonable based on the actuated one or more filters.
22. The non-transitory computer readable media of claim 21 , wherein the actuated one or more filters includes a billing guidelines filter, and the program instructions further include:
identifying a billing guideline associated with the proposed medical service;
determining that the proposed charge amount is presumptively reasonable if the proposed charge amount complies with the identified billing guideline; and
determining that the proposed charge amount is presumptively unreasonable if the proposed charge amount fails to comply with the identified billing guideline.