Use determination risk coverage datastructure for on-demand and increased efficiency coverage detection and rebalancing apparatuses, methods and systems
The Use Determination Risk Coverage Datastructure for On-Demand and Increased Efficiency Coverage Detection and Rebalancing Apparatuses, Methods and Systems (“UDRCD”) transforms coverage enrollment request, event signal, ACGG request, search request inputs via UDRCD components into coverage enrollment response, add-in recommendation, ACGG response, search response outputs. An add-in recommendation request associated with a plan member is obtained. A condition associated with the request is determined. A set of treatment paths associated with the condition is determined. A member state associated with the plan member is determined. The plan member's treatment path location is determined. A high value treatment path is determined from available treatment paths. An atomized add-in that provides coverage for the treatment path is determined. A set of providers for the atomized add-in is determined, and an expected longitudinal treatment value and copay are calculated for each provider. A best provider is determined. An atomized add-in recommendation is provided.
1 . A system comprising:
one or more processors; and
at least one memory storing processor-executable instructions that, when executed by the one or more processors, cause the one or more processors to perform operations comprising:
receiving an add-in recommendation request associated with a plan data structure;
generating, based on clinical condition data, a use determination risk coverage graph topology data structure (UDRCD) comprising an atomized coverage graph depicting a set of one or more treatment paths, a set of one or more treatment objects associated with the set of one or more treatment paths, and a set of one or more provider objects associated with the set of one or more treatment paths, wherein:
(i) a first provider object of the set of one or more provider objects specifies a likelihood that a provider utilizes a treatment path of the set of one or more treatment paths,
(ii) the atomized coverage graph comprises a self-updating data structure configured to perform self-updating of the self-updating data structure based on updated treatment path data, and
(iii) the UDRCD comprises a multi-directional and self-referential data structure;
determining, based on event signal data associated with a plan member associated with the plan data structure, a condition associated with the add-in recommendation request;
determining, based on the set of one or more treatment objects and the set of one or more provider objects of the UDRCD, a second set of one or more treatment paths associated with the condition, wherein a first treatment path of the second set of one or more treatment paths comprises a first subset of treatment pathway nodes of the UDRCD;
identifying, based on clinical data associated with the plan member specific to the second set of one or more treatment paths, a plan member treatment path location;
selecting, based on a second subset of treatment pathway nodes of the UDRCD and the plan member treatment path location, an available treatment path of the set of one or more treatment paths of the set of one or more treatment paths comprising a key treatment pathway node corresponding to the plan member treatment path location;
determining, based on provider data, a set of one or more providers providing an atomized add-in that provides coverage for the available treatment path;
determining, based on evaluating a set of one or more expected longitudinal treatment values associated with the set of one or more providers, a selected provider from the set of one or more providers that is associated with a lowest expected longitudinal treatment value of the set of one or more expected longitudinal treatment values relative to other providers of the set of one or more providers;
generating, based on the available treatment path, the atomized add-in, and the selected provider, an atomized add-in recommendation for the plan member; and
generating, a user interface configured to provide (i) a display of the atomized add-in recommendation for the plan member and (ii) an interface component configured to receive data for supplementing the atomized add-in recommendation.
2 . The system of claim 1 , wherein the operations further comprise:
receiving an event signal corresponding to the plan member, wherein the event signal comprises one or more of: a coverage search by the plan member, a health care electronic data interchange transaction associated with the plan member, or an electronic health information message associated with the plan member; and
determining, further based on the event signal, the condition associated with the add-in recommendation request.
3 . The system of claim 1 , wherein the condition associated with the add-in recommendation request is determined further based on a coverage search query specified by the plan member.
4 . The system of claim 1 , wherein the atomized coverage graph is configured to perform self-updating further based on data for supplementing the atomized add-in recommendation as received via the interface component.
5 . The system of claim 1 , wherein to determine the set of one or more treatment paths associated with the condition, the operations further comprise:
determining a clinical condition object in the atomized coverage graph corresponding to the condition associated with the add-in recommendation request; and
determining a treatment paths object in the atomized coverage graph associated with the clinical condition object.
6 . The system of claim 1 , wherein the plan member treatment path location is determined further based on a treatment path move sequence associated with the plan member.
7 . The system of claim 1 , wherein the atomized add-in is a treatment add-in that provides coverage for a next treatment that the plan member must utilize to follow the available treatment path from the plan member treatment path location.
8 . The system of claim 1 , wherein the atomized add-in is a condition add-in that provides coverage for the condition.
9 . The system of claim 1 , wherein the operations further comprise:
determining a provider object in the atomized coverage graph corresponding to a respective provider of the set of one or more providers;
determining a propensity ranking based on practice patterns data associated with the provider object;
determining a propensity weight based on the plan member treatment path location;
determining an expected episodic cost for a next expected treatment for the condition based on treatment cost data associated with the provider object;
determining an episodic cost weight based on the plan member treatment path location; and
determining an expected longitudinal treatment value for the respective provider as a weighted average of the propensity ranking, weighted by the propensity weight, and the expected episodic cost weighted by the episodic cost weight.
10 . The system of claim 1 , wherein the operations further comprise:
determining a base copay for the atomized add-in based on an average longitudinal treatment value for the set of one or more providers;
determining, for a respective provider, a price factor indicative of a relative expense of an expected longitudinal treatment value for the respective provider as compared with the average longitudinal treatment value for other providers in the set of one or more providers; and
determining a copay for the atomized add-in for the respective provider as the base copay for the respective provider adjusted by the price factor for the respective provider.
11 . The system of claim 10 , wherein the set of one or more providers comprises one or more providers in a region associated with the plan member.
12 . The system of claim 1 , wherein a copay for the atomized add-in is adjusted based on a treatment path move sequence associated with the plan member.
13 . The system of claim 1 , wherein the operations further comprise:
generating, via an enrollment user interface, a notification with the atomized add-in recommendation for the plan member;
receiving, via the enrollment user interface, a selection of the atomized add-in from the plan member; and
providing, via the enrollment user interface, information regarding the set of one or more providers available for the atomized add-in, wherein the selected provider is highlighted for the plan member.
14 . The system of claim 13 , wherein the information regarding the set of one or more providers available for the atomized add-in comprises a map component that shows a location of each provider and a copay associated with each provider on a map.
15 . One or more non-transitory computer-readable storage media storing instructions that, when executed by one or more processors, cause the one or more processors to perform operations comprising:
receiving an add-in recommendation request associated with a plan data structure;
generating, based on clinical condition data, a use determination risk coverage graph topology data structure (UDRCD) comprising an atomized coverage graph depicting a set of one or more treatment paths, a set of one or more treatment objects associated with the set of one or more treatment paths, and a set of one or more provider objects associated with the set of one or more treatment paths, wherein;
(i) a first provider object of the set of one or more provider objects specifies a likelihood that a provider utilizes a treatment path of the set of one or more treatment paths,
(ii) the atomized coverage graph is a self-updating data structure configured to perform self-updating of the self-updating data structure based on updated treatment path data, and
(iii) the UDRCD comprises a multi-directional and self-referential data structure;
determining, based on event signal data associated with a plan member associated with the plan data structure, a condition associated with the add-in recommendation request;
determining, based on the set of one or more treatment objects and the set of one or more provider objects of the UDRCD, a second set of one or more treatment paths associated with the condition wherein a first treatment path of the second set of one or more treatment paths comprises a first subset of one or more treatment pathway nodes of the UDRCD;
identifying, based on clinical data associated with the plan member specific to the second set of one or more treatment paths, a plan member treatment path location;
selecting, based on a second sub-set of treatment pathway nodes of the UDRCD and the plan member treatment path location, an available treatment path of the set of one or more treatment paths comprising a key treatment pathway node corresponding to the plan member treatment path location;
determining, based on provider data, a set of one or more providers providing an atomized add-in that provides coverage for the available treatment path;
determining, based on evaluating a set of one or more expected longitudinal treatment values associated with the set of one or more providers, a selected provider from the set of one or more providers that is associated with a lowest expected longitudinal treatment value of the set of one or more expected longitudinal treatment values relative to other providers of the set of one or more providers;
generating, based on the available treatment path, the atomized add-in, and the selected provider, an atomized add-in recommendation for the plan member; and
generating, a user interface configured to provide (i) a display of the atomized add-in recommendation for the plan member and (ii) an interface component configured to receive data for supplementing the atomized add-in recommendation.
16 . A processor-implemented add-in upgrade recommendation system, comprising:
an add-in recommendation determining component means, to:
receiving an add-in recommendation request associated with a plan data structure;
generating, based on clinical condition data, a use determination risk coverage graph topology data structure (UDRCD) comprising an atomized coverage graph depicting a set of one or more treatment paths, a set of one or more treatment objects associated with the set of one or more treatment paths, and a set of one or more provider objects associated with the set of one or more treatment paths, wherein:
(i) a first provider object of the set of one or more provider objects specifies a likelihood that a provider utilizes a treatment path of the set of one or more treatment paths,
(ii) the atomized coverage graph is a self-updating data structure configured to perform self-updating of the self-updating data structure based on updated treatment path data, and
(iii) the UDRCD comprises a multi-directional and self-referential data structure;
determining, based on event signal data associated with a plan member associated with the plan data structure, a condition associated with the add-in recommendation request;
determining, based on the set of one or more treatment objects and the set of one or more provider objects of the UDRCD, a second set of one or more treatment paths associated with the condition wherein a first treatment path of the second set of one or more treatment paths comprises a first subset of one or more treatment pathway nodes of the UDRCD;
identifying, based on clinical data associated with the plan member specific to the second set of one or more treatment paths, a plan member treatment path location;
selecting, based on a second sub-set of treatment pathway nodes of the UDRCD and the plan member treatment path location, an available treatment path of the set of one or more treatment paths comprising a key treatment pathway node corresponding to the plan member treatment path location;
determining, based on provider data, a set of one or more providers providing an atomized add-in that provides coverage for the available treatment path;
determining, based on evaluating a set of one or more expected longitudinal treatment values associated with the set of one or more providers, a selected provider from the set of one or more providers that is associated with a lowest expected longitudinal treatment value of the set of one or more expected longitudinal treatment values relative to other providers of the set of one or more providers;
generating, based on the available treatment path, the atomized add-in, and the selected provider, an atomized add-in recommendation for the plan member; and
generating, a user interface configured to provide (i) a display of the atomized add-in recommendation for the plan member and (ii) an interface component configured to receive data for supplementing the atomized add-in recommendation.
17 . A processor-implemented add-in upgrade recommendation method, comprising:
receiving, by one or more processors, an add-in recommendation request associated with a plan data structure;
generating, by the one or more processors and based on a set of clinical condition data, a use determination risk coverage graph topology data structure (UDRCD) comprising an atomized coverage graph depicting a set of one or more treatment paths, a set of one or more treatment objects associated with the set of one or more treatment paths, and a set of one or more provider objects associated with the set of one or more treatment paths, wherein;
(i) a first provider object of the set of one or more provider objects specifies a likelihood that a provider utilizes a treatment path of the set of one or more treatment paths,
(ii) the atomized coverage graph is a self-updating data structure configured to perform self-updating of the self-updating data structure based on updated treatment path data, and
(iii) the UDRCD comprises a multi-directional and self-referential data structure;
determining, by the one or more processors and based on event signal data associated with a plan member associated with the plan data structure, a condition associated with the add-in recommendation request;
determining, by the one or more processors and based on the set of one or more treatment objects and the set of one or more provider objects of the UDRCD, a second set of one or more treatment paths associated with the condition wherein a first treatment path of the second set of one or more treatment paths comprises a first subset of one or more treatment pathway nodes of the UDRCD;
identifying, by the one or more processors and based on clinical data associated with the plan member specific to the second set of one or more treatment paths, a plan member treatment path location;
selecting, by the one or more processors and based on a second subset of treatment pathway nodes of the UDRCD and the plan member treatment path location, an available treatment path of the set of one or more treatment paths comprising a key treatment pathway node corresponding to the plan member treatment path location;
determining, by the one or more processors and based on a set of provider data, a set of one or more providers providing an atomized add-in that provides coverage for the available treatment path;
determining, by the one or more processors and based on evaluating a set of one or more expected longitudinal treatment values associated with the set of one or more providers, a selected provider from the set of one or more providers that is associated with a lowest expected longitudinal treatment value of the set of one or more expected longitudinal treatment values relative to other providers of the set of one or more providers;
generating, by the one or more processors and based on the available treatment path, the atomized add-in, and the selected provider, an atomized add-in recommendation for the plan member; and
generating, by the one or more processors, a user interface configured to provide (i) a display of the atomized add-in recommendation for the plan member and (ii) an interface component configured to receive data for supplementing the atomized add-in recommendation.