Computer-implemented method for grouping medical claims into episode treatment groups
A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.
1. A system for processing medical claims data, comprising:
a processor; and
a storage medium operably coupled to the processor, wherein the storage medium stores program instructions that, when executed by the processor, cause the processor to:
group a plurality of medical claim data records to an episode of care having at least one defining characteristic;
assign a first clean period to the episode of care, the first clean period defined by a predefined time duration during which there is an absence of medical claim data having the at least one defining characteristic of the episode treatment group; and
reset the first clean period to define a second clean period, the second clean period defining a second predefined time duration, wherein the first clean period is reset to the second clean period when later presented medical claim data having the at least one characteristic of the episode of care and falling within the first clean period is added to the episode of care.
2. A computer readable storage medium storing instructions, which upon execution by an apparatus, causes the apparatus to perform operations comprising:
grouping a plurality of medical claim data records to an episode of care having at least one defining characteristic;
assigning a first clean period to the episode of care, the first clean period defined by a predefined time duration during which there is an absence of medical claim data having the at least one defining characteristic of the episode treatment group; and
resetting the first clean period to define a second clean period, the second clean period defining a second predefined time duration, wherein the first clean period is reset to the second clean period when later presented medical claim data having the at least one characteristic of the episode of care and falling within the first clean period is added to the episode of care.
3. A system for processing medical claims data, comprising:
one or more medical claim data records each including at least one of a diagnosis, procedure or drug code;
a processor; and
a storage medium operably coupled to the processor, wherein the storage medium stores program instructions that, when executed by the processor, cause the processor to:
store a plurality of diagnostic groups in the storage medium, wherein each diagnostic group is associated with one or more diagnosis, procedure or drug codes;
process a first medical claim data record upon receiving the first medical claim data record associated with a patient, wherein the processing comprises:
identifying one or more diagnosis, procedure or drug codes in the first medical claim data record;
comparing the identified codes in the first medical claim data record with the codes associated with one or more of the plurality of the stored diagnostic groups; and
assigning the first medical claim data record to a first diagnostic group based upon the one or more diagnosis, procedure or drug codes identified in the first medical claim data record; and
process a second medical claim data record upon receiving a second medical claim data record associated with the patient, wherein the processing comprises:
identifying one or more diagnosis, procedure or drug codes in the second medical claim data record;
determining whether the identified codes in the second medical claim data record indicate a change in the patient's clinical condition; and
shifting the first medical claim data record from the first diagnostic group to a second diagnostic group that includes the change in the patient's clinical condition.
4. The system of claim 3 , wherein the change in the patient's clinical condition indicated by the codes in the second medical claim data record represents a complication, co-morbidity, surgery or changed severity of clinical condition of the patient.
5. The system of claim 3 , wherein the program instructions further cause the processor to:
process a third medical claim data record upon receiving the third medical claim data record associated with a patient, wherein the processing comprises:
identifying one or more diagnosis, procedure or drug codes in the third medical claim data record;
determining whether the identified codes in the third medical claim data record indicate an additional change in the patient's clinical condition, and if so, shifting the first medical claim data record from the second diagnostic group to a third diagnostic group that includes the additional change in the patient's clinical condition.
6. The system of claim 5 , wherein the change in the patient's clinical condition indicated by the codes in the third medical claim data record represents a complication, co-morbidity, surgery or changed severity of clinical condition by the patient.
7. The system of claim 3 , wherein the diagnostic groups are episode treatment groups.
8. A computer readable storage medium storing instructions, which upon execution by an apparatus, causes the apparatus to perform operations comprising:
providing one or more medical claim data records each including at least one of a diagnosis, procedure or drug code;
storing a plurality of diagnostic groups in an electronic storage medium, wherein each diagnostic group is associated with one or more diagnosis, procedure or drug codes;
processing a first medical claim data record upon receiving the first medical claim data record associated with a patient, wherein the processor further causes the apparatus to perform operations comprising:
identifying one or more diagnosis, procedure or drug codes in the first medical claim data record;
comparing the identified codes in the first medical claim data record with the codes associated with one or more of the plurality of the stored diagnostic groups; and
assigning the first medical claim data record to a first diagnostic group based upon the one or more diagnosis, procedure or drug codes identified in the first medical claim data record; and
processing a second medical claim data record upon receiving a second medical claim data record associated with the patient, wherein the processor further causes the apparatus to perform operations comprising:
identifying one or more diagnosis, procedure or drug codes in the second medical claim data record;
determining whether the identified codes in the second medical claim data record indicate a change in the patient's clinical condition; and
shifting the first medical claim data record from the first diagnostic group to a second diagnostic group that includes the change in the patient's clinical condition.
9. The computer readable storage medium of claim 8 , wherein the change in the patient's clinical condition indicated by the codes in the second medical claim data record represents a complication, co-morbidity, surgery or changed severity of clinical condition of the patient.
10. The computer readable storage medium of claim 8 , wherein the instructions further cause the apparatus to:
process a third medical claim data record upon receiving the third medical claim data record associated with a patient, wherein the apparatus performs the operations comprising:
identifying one or more diagnosis, procedure or drug codes in the third medical claim data record;
determining whether the identified codes in the third medical claim data record indicate an additional change in the patient's clinical condition, and if so, shifting the first medical claim data record from the second diagnostic group to a third diagnostic group that includes the additional change in the patient's clinical condition.
11. The computer readable storage medium of claim 10 , wherein the change in the patient's clinical condition indicated by the codes in the third medical claim data record represents a complication, co-morbidity, surgery or changed severity of clinical condition by the patient.
12. The computer readable storage medium of claim 8 , wherein the diagnostic groups are episode treatment groups.