Payer provider connect engine
Systems, methods and computer program products to identify and close gaps in care are provided. Aspects of the present disclosure disclosed and described herein enable a payer may identify gaps in care based on information in the payer database. The payer can send this information to the provider prior to patient scheduling. The scheduling system at the provider can use this information to schedule patients and their medical needs (e.g., medical test, lab tests, imaging tests, etc.) before the next patient appointment. Primary care providers (PCPs) can then be made aware of the gaps in care information, as well as Hierarchical Condition Category (HCC) coding gap information, so they can perform a complete diagnosis using all available clinical data. PCP notes along with the treatment the patient receives can be combined with the RAF (Risk Adjustment Score) shared by the payers to ensure patient is assessed for all relevant conditions during the visit. Payers can then be informed electronically that the gap in care has been closed; the payer can also receive the resultant claims such that correct RAF scores can be computed and HCC coding gaps can be closed.
1. A payer provider connectivity apparatus, the apparatus comprising:
a connect engine in communication with a first payer system, a second payer system, and a plurality of provider systems via a network, the connect engine to receive, via the network, medical codes including a first code from the first payer system corresponding to a patient and a second code from the second payer system corresponding to the patient;
the connect engine including:
a database to store the medical codes and instructions for execution; and
a processor to execute the instructions to at least:
transform the medical codes to a common format, the common format to standardize the first code with the second code to determine a coding gap of the patient, wherein the coding gap is indicative of a gap in care of the patient; and
when the connect engine determines the coding gap of the patient:
reconcile the coding gap with a scheduling gap of the patient to schedule an appointment to address the gap in care of the patient, wherein the scheduling gap is indicative of an available time for a provider to remedy the gap in care for the patient; and
a plurality of smart agents including at least a first smart agent structured to be deployed to a first provider system and a second smart agent structured to be deployed to a second provider system of the plurality of provider systems to enable communication between the first and second provider systems, at least one of the first payer system or the second payer system, and the connect engine, the first smart agent and the second smart agent further structured to process data related to the coding gap when deployed at the respective first provider system and the second provider system, the first smart agent and the second smart agent in communication with the connect engine to:
reconcile and remove the coding gap from the database corresponding to the patient;
compute a risk adjustment score with at least one of the first payer system or the second payer system based on a claim diagnosis code triggered by removal of the coding gap; and
coordinate the appointment scheduled for the patient based on the removal of the gap in care of the patient and the risk adjustment score.
2. The apparatus of claim 1 , wherein the gap in care is a gap in a medical care of the patient, wherein the patient is affected negatively by the gap in care.
3. The apparatus of claim 1 , wherein the first payer system is to generate a first member roster file and the second payer system is to generate a second member roster file, the first and second member roster files indicative of a plurality of patients associated with the first payer system and the second payer system.
4. The apparatus of claim 3 , wherein the connect engine is to receive the first member roster file from the first payer system and the second member roster file from the second payer system, the connect engine further including the processor to:
transform the first member roster file and the second member roster file to a common format to determine a complete member list of the first payer system and the second payer system;
reconcile the complete member list with a previous member list to generate a roster exception corresponding to an enrollment status of the plurality of patients; and
generate instructions to be executed by the respective smart agent at one of the plurality of provider systems to facilitate updating the enrollment status of the plurality of patients.
5. The apparatus of claim 1 , wherein the connect engine is to generate a member coding gap file when a first provider system and a second provider system provide a medical code of the patient, the member coding gap file to provide updated information corresponding to a patient medical care to the plurality of provider systems.
6. The apparatus of claim 1 , further including a scheduler to receive instructions from the respective smart agent and schedule the appointment based on the gap in care.
7. A method comprising:
communicating, via a network using a connect engine including a processor, with a first payer system, a second payer system, and a plurality of provider systems, the connect engine to receive, via the network, medical codes including a first code from the first payer system corresponding to a patient and a second code from the second payer system corresponding to the patient;
storing, in a database using the connect engine, the medical codes and instructions for execution;
transforming, using the connect engine, the medical codes to a common format, the common format to standardize the first code with the second code to determine a coding gap of the patient, wherein the coding gap is indicative of a gap in care of the patient;
removing, using at least a first smart agent structured to be deployed to a first provider system and a second smart agent structured to be deployed to a second provider system of the plurality of provider systems to enable communication between the first and second provider systems, at least one of the first payer system or the second payer system, and the connect engine, the coding gap from the database corresponding to the patient, the first smart agent and the second smart agent further structured to process data related to the coding gap when deployed at the respective first provider system and the second provider system;
computing, using the respective smart agent, a risk adjustment score with at least one of the first payer system or the second payer system based on a claim diagnosis code triggered by removal of the coding gap; and
coordinating the appointment scheduled for the patient, using the respective smart agent, with the connect engine based on removal of the gap in care of the patient and the risk adjustment score.
8. The method of claim 7 , wherein the gap in care is a gap in a medical care of the patient, wherein the patient is affected negatively by the gap in care.
9. The method of claim 7 , further including generating a first member roster file and a second member roster file, the first and second member roster file indicative of a plurality of patients associated with the first payer system and the second payer system.
10. The method of claim 9 , further including receiving the first member roster file from the first payer system and the second member roster file from the second payer system, and further including:
transforming the first member roster file and the second member roster file to a common format to determine a complete member list of the first payer system and the second payer system;
reconciling the complete member list with a previous member list to generate a roster exception corresponding to an enrollment status of the plurality of patients; and
generating instructions to be executed at one of the plurality of provider systems to facilitate updating the enrollment status of the plurality of patients.
11. The method of claim 7 , further including generating a member coding gap file when the first payer system and the second payer system provide a medical code of the patient, the member coding gap file to provide updated information corresponding to a patient medical care to the plurality of provider systems.
12. The method of claim 7 , further including receiving instructions and scheduling the appointment based on the gap in care.
13. A non-transitory computer readable storage medium comprising instructions that, when executed, cause at least one processor to at least:
communicate, via a network using a connect engine, with a first payer system, a second payer system, and a plurality of provider systems, the connect engine to receive, via the network, medical codes including a first code from the first payer system corresponding to a patient and a second code from the second payer system corresponding to the patient;
store, in a database, the medical codes and instructions for execution;
transform the medical codes to a common format, the common format to standardize the first code with the second code to determine a coding gap of the patient, wherein the coding gap is indicative of a gap in care of the patient;
reconcile, when the processor determines the coding gap of the patient, the coding gap with a scheduling gap of the patient to schedule an appointment to address the gap in care of the patient, wherein the scheduling gap is indicative of an available time for a provider to remedy the gap in care for the patient;
remove, using at least a first smart agent structured to be deployed to a first provider system and a second smart agent structured to be deployed to a second provider system of the plurality of provider systems to enable communication between the first and second provider systems, at least one of the first payer system or the second payer system, and the connect engine, the coding gap from the database corresponding to the patient, the first smart agent and the second smart agent further structured to process data related to the coding gap when deployed at the respective first provider system and the second provider system;
compute, using the respective smart agent, a risk adjustment score with at least one of the first payer system or the second payer system based on a claim diagnosis code triggered by removal of the coding gap; and
coordinate the appointment scheduled for the patient, using the respective smart agent, with the connect engine based on removal of the gap in care of the patient and the risk adjustment score.
14. The tangible computer readable storage medium as defined in claim 13 , wherein the instructions, when executed, further cause the processer to associate the gap in care with a gap in a medical care of the patient, wherein the patient is affected negatively by the gap in care.
15. The tangible computer readable storage medium as defined in claim 13 , wherein the instructions, when executed, further cause the processer to generate a first member roster file and the second payer system is to generate a second member roster file, the first and second member roster file indicative of a plurality of patients associated with the first payer system and the second payer system.
16. The tangible computer readable storage medium as defined in claim 15 , wherein the instructions, when executed, further cause the processer to receive the first member roster file from the first payer system and the second member roster file from the second payer system;
transform the first member roster file and the second member roster file to a common format to determine a complete member list of the first payer system and the second payer system;
reconcile the complete member list with a previous member list to generate a roster exception corresponding to an enrollment status of the plurality of patients; and
generate instructions to be executed at one of the plurality of provider systems to facilitate updating the enrollment status of the plurality of patients.
17. The tangible computer readable storage medium as defined in claim 13 , wherein the instructions, when executed, further cause the processer to generate a member coding gap file when a first provider system and a second provider system provide a medical code of the patient, the member coding gap file to provide updated information corresponding to a patient medical care to the plurality of provider systems.
18. The tangible computer readable storage medium as defined in claim 13 , wherein the instructions, when executed, further cause the processer to receive instructions and schedule the appointment based on the gap in care.