System and method for processing payment bundles
A system and process for prospectively creating patient episodes of care and triggering associated payment bundles during the claim adjudication process facilitates real-time claim pricing in accordance with payment bundle rules to facilitate episodic payment in place of pay-for-service payment. Additionally, various processes are described for modeling patient episodes and payment bundles and unbundling episodic payments.
1. A process for modeling payment bundles using historical claims data comprising:
importing, into at least a first modeler claims database, historical claims data for multiple types of claims;
selecting, by payment bundling logic operating on at least one processor, at least one representative claim for payment bundle modeling, wherein the at least one representative claim is selected based on at least one of the following group consisting of type of medical procedure, provider specialty, provider name, patient condition and location of medical procedure;
modifying, by the payment bundling logic, the data associated with the selected at least one representative claim to reflect a specific date range, wherein the specific data range includes therein a date for each medical procedure from the selected at least one representative claim;
reviewing, by the payment bundling logic, the modified data associated with the selected at least one representative claim to identify at least one event therein to use to trigger a payment bundle;
searching, by the payment bundling logic, the at least a first modeler claims database, to identify additional claims related to the representative claim, wherein a claim is related if it falls in the specific date range and meets one or more additional predetermined criteria;
associating, by the payment bundling logic, the representative claim and identified related additional claims with the identified at least one event used to trigger a payment bundle; and
determining, by the payment bundling logic, a modeled price for the payment bundle, wherein the modeled price includes a single payment for the combination of the representative claim and any identified related claims.
2. The process in accordance with claim 1 , wherein the at least one event that triggers a payment bundle is identification by the payment bundling logic of a specific diagnosis related group (DRG) code in a claim.
3. The process in accordance with claim 1 , further comprising:
comparing, by the payment bundling logic, the modeled price for the payment bundle against the sum of individual payment amounts for each of the representative claims and identified related claims; and
updating the payment bundle to exclude one or more of the identified related claims therefrom.
4. The process in accordance with claim 1 , wherein the one or more additional predetermined criteria includes a same patient ID.
5. The process in accordance with claim 1 , wherein the payment bundling logic further models distribution of the single payment in allowed amounts to one or more providers associated with the representative claim and identified related additional claims in the payment bundle.
6. The process in accordance with claim 5 , wherein the payment bundling logic applies one or more rules that vary individual allowed amounts in accordance with one or more of an original fee-for-service amount under an applicable representative claim and identified related additional claims in the payment bundle, complications experienced by a patient associated with the representative claim and identified related additional claims in the payment bundle, and secondary diagnoses attributed to the patient associated with the representative claim and identified related additional claims in the payment bundle.
7. The process in accordance with claim 5 , wherein the payment bundling logic applies one or more rules that vary individual allowed amounts in accordance with a defined role of one or more providers associated with the representative claim and identified related additional claims in the payment bundle.
8. A processor programmed with executable code for modeling payment bundles using historical claims data comprising:
first payment bundling logic for selecting at least one representative claim for payment bundle modeling;
second payment bundling logic for modifying data associated with the selected at least one representative claim to reflect a specific date range, wherein the specific data range includes therein a date for each medical procedure from the selected at least one representative claim;
third payment bundling logic for analyzing the modified data associated with the selected at least one representative claim to identify at least one event therein to use to trigger a payment bundle;
fourth payment bundling logic for searching at least a first modeler claims database, to identify additional claims related to the representative claim, wherein a claim is related if it falls in the specific date range and meets one or more additional predetermined criteria;
fifth payment bundling logic for associating the representative claim and identified related additional claims with the identified at least one event used to trigger a payment bundle; and
sixth payment bundling logic for determining a modeled price for the payment bundle, wherein the modeled price includes a single payment for the combination of the representative claim and any identified related claims.
9. The processor of claim 8 , wherein the at least one representative claim is selected based on at least one of the following group consisting of type of medical procedure, provider specialty, provider name, patient condition and location of medical procedure.
10. The processor in accordance with claim 8 , wherein the at least one event that triggers a payment bundle is identification by the payment bundling logic of a specific diagnosis related group (DRG) code in a claim.
11. The processor in accordance with claim 8 , further comprising:
seventh payment bundling logic for comparing the modeled price for the payment bundle against the sum of individual payment amounts for each of the representative claims and identified related claims and updating the payment bundle to exclude one or more of the identified related claims therefrom.
12. The processor in accordance with claim 8 , wherein the one or more additional predetermined criteria includes a same patient ID.
13. The processor in accordance with claim 8 , comprising seventh payment bundling logic for modeling distribution of the single payment in allowed amounts to one or more providers associated with the representative claim and identified related additional claims in the payment bundle.
14. The processor in accordance with claim 13 , wherein the eighth payment bundling logic applies one or more rules that vary individual allowed amounts in accordance with one or more of an original fee-for-service amount under an applicable representative claim and identified related additional claims in the payment bundle, complications experienced by a patient associated with the representative claim and identified related additional claims in the payment bundle, and secondary diagnoses attributed to the patient associated with the representative claim and identified related additional claims in the payment bundle.
15. The processor in accordance with claim 13 , wherein the eighth payment bundling logic applies one or more rules that vary individual allowed amounts in accordance with a defined role of one or more providers associated with the representative claim and identified related additional claims in the payment bundle.