Computerized system and methods of adjudicating medical appropriateness
A method for adjudicating and reimbursing a care provider for services provided for a clinical event is provided. The method includes the step of receiving a transaction having a number of clinical data elements. The method also includes the steps of accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer. The method also includes the steps of accessing a first knowledge base comprising evidence-based standards for providing medically appropriate care and selectively performing analysis of the clinical data elements of the transaction against at least one standard to determine if the care provided is medically appropriate. The method further includes the steps of accessing a second knowledge base containing at least one criterion for assessing quality of care and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine if the care provided is medically appropriate. Also, the method includes determining a level of reimbursement based on the medical appropriateness and quality of the care provided and authorizing reimbursement of the care provider from at least one payer.
1. One or more computer-storage media having computer-useable instructions embodied thereon for performing a method for adjudicating and reimbursing a care provider for services provided for a clinical event, the method comprising:
receiving a transaction including a number of clinical event details electronically documented by a care provider at a point of care for the clinical event for which reimbursement is sought;
accessing a first knowledge base comprising a number of evidence-based options for providing medically appropriate care;
automatically selecting one or more options based on the clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought;
performing analysis of the clinical event details against the selected at least one option to determine the appropriateness of medical care;
determining a level of reimbursement for a patient based on the appropriateness of medical care provided to the patient using electronic health record data elements associated with the patient from an electronic health record data store of a central computing system having historical electronic health record data elements received from a plurality of sources and using corresponding clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought; and
reimbursing the provider in real-time.
2. The media according to claim 1 , further comprising accessing the electronic health record data store including a plurality of electronic health record data elements.
3. The media according to claim 2 , wherein the step of selecting at least one clinical option is further based on one or more EHR data elements.
4. The media according to claim 1 , further comprising accessing a data store including payer information and determining whether the transaction is eligible for reimbursement by at least one payer.
5. The media according to claim 1 , further comprising accessing a second knowledge base comprising at least one criterion for assessing quality of care and selectively performing analysis of the clinical data elements of the transaction against the at least one criterion to determine the quality of care.
6. The media according to claim 1 , further comprising authorizing reimbursement of the care provider from the at least one payer.
7. The media according to claim 1 , wherein the clinical options consist of guidelines and standards.
8. One or more computer-storage media having computer-useable instructions embodied thereon for performing a method for adjudicating and reimbursing a care provider for services provided for a clinical event, the method comprising:
receiving a transaction including a number of clinical event details electronically documented by a care provider at a point of care for the clinical event for which reimbursement is sought;
accessing a first knowledge base comprising a number of evidence-based options for providing medically appropriate care;
selecting one or more options based on the clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought;
automatically determining that one or more electronic health record (EHR) data elements associated with a patient affect the selected one or more options;
in response to the determination that the one or more EHR data elements affect the selected one or more options, adjusting the selected one or more options;
performing analysis of the clinical event details against the adjusted one or more options to determine the appropriateness of medical care; and
determining an amount of reimbursement for the patient based on the appropriateness of medical care provided to the patient using electronic health record data elements associated with the patient from an electronic health record data store of a central computing system having historical electronic health record data elements received from a plurality of sources and using corresponding clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought; and
reimbursing the provider in real-time.
9. One or more computer-storage media having computer-useable instructions embodied thereon for performing a method for adjudicating and reimbursing a care provider for services provided for a clinical event, the method comprising:
receiving a transaction including a number of clinical event details electronically documented by a care provider at a point of care for the clinical event for which reimbursement is sought;
accessing a first knowledge base comprising a number of evidence-based options for providing medically appropriate care;
automatically selecting one or more options based on the clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought;
determining that one or more electronic health record (EHR) data elements associated with a patient affect the selected one or more options;
in response to the determination that the one or more EHR data elements affect the selected one or more options, adjusting the selected one or more options;
performing analysis of the clinical event details against the adjusted one or more options to determine the appropriateness of medical care, wherein when the clinical event details initially fail satisfy the adjusted one or more options, the appropriateness of medical care is determined by
(1) providing a notification to the care provider indicating that the one or more options have not been satisfied,
(2) receiving a reason from the care provider for the failure to satisfy the adjusted one or more options, and
(3) determining whether the reason is acceptable based on a predetermined set of acceptable reasons;
determining an amount of reimbursement for the patient based on the appropriateness of medical care provided to the patient using electronic health record data elements associated with the patient from an electronic health record data store of a central computing system having historical electronic health record data elements received from a plurality of sources and using corresponding clinical event details electronically documented by the care provider at the point of care for the clinical event for which reimbursement is sought; and
reimbursing the provider in real-time.