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, shills 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 computer-implemented process for profiling medical claims including the steps of:
(a) reading a first patient's medical claim data, input as at least one of a plurality of data records, into a computer memory;
(b) validating each of the at least one of a plurality of data records for at least one of a diagnosis code and a treatment code using a computer processor;
(c) reading at least one pre-defined relation between the at least one of a diagnosis code and a treatment code in the validated at least one of a plurality of data records and pre-defined medical episodes using the computer processor; and
(d) grouping the validated at least one of a plurality of data records to at least one of a plurality of episode treatment groups, each of the at least one of a plurality of episode treatment groups further comprising one anchor record and n data records linked thereto using the computer processor, the n data records being selected from the group consisting of ancillary records, facility records and prescription drug records, where n is an integer greater than or equal to 0, and having a predefined time window during which the n data records may group to the one anchor record.
2. The process as claimed in claim 1 , wherein each of the at least one of a plurality of episode treatment groups contain at least one cluster.
3. The process as claimed in claim 2 , wherein the at least one cluster further comprises at least one ancillary record and at least one anchor record.
4. The process as claimed in claim 1 , wherein the step (d) further comprises the step of differentiating patient severity based upon data relating to at least one of patient age, complications, conditions, comorbidities and major surgeries.
5. The process as claimed in claim 1 , further comprising the step of outputting and discontinuing processing of invalid data records and comparing diagnosis and treatment code data using the computer processor.
6. The process as claimed in claim 5 wherein the step of outputting and discontinuing processing of invalid data records further includes the step of assigning a different episode treatment group for at least one of an invalid diagnosis code, an invalid treatment code and an invalid provider type.
7. The process as claimed in claim 1 , further comprising the step of identifying valid episode treatment groups by comparing current treatment codes to prior related episodes in look-up tables using the computer processor.
8. The process as claimed in claim 1 , further comprising the step of flagging valid claim records with a diagnosis code identifier using the computer processor.
9. The process as claimed in claim 8 , wherein the step of flagging valid claim records further comprises the step of incrementing a sequential anchor count and a sequential episode count for each episode treatment group assignment.
10. The process as claimed in claim 1 , further comprising the step of resetting a dynamic time window of a medical episode of the pre-defined medical episodes when a second at least one of a plurality of data records matches an open medical episode using the computer processor, the dynamic time window being reset for an additional period of time until no other data records are grouped to the open medical episode within the reset dynamic time window.
11. The process as claimed in claim 10 , wherein the step of resetting the dynamic time window of the medical episode, further comprises the step of selecting a most recent claim record if more than one matched claim record exists.
12. The process as claimed in claim 1 , further comprising the step of shifting a medical claim to a different one of the plurality of episode treatment groups based upon an inputting of a medical claim record including changes in patient condition comprising at least one of comorbidity, complication and defining surgery using the computer processor.
13. The process as claimed in claim 12 , wherein the step of shifting further comprises shifting an episode treatment group originally assigned by a first diagnosis on a medical claim record based on at least one of a second, third and fourth diagnosis.
14. The process as claimed in claim 7 , wherein the step of identifying valid episode treatment groups further comprises the step of comparing pharmaceutical claim data in a patient's medical claim data to open episode treatment groups for the patient by analyzing Generic Drug Codes by episode treatment group and National Drug Code by Generic Drug Codes look-up tables.
15. The process as claimed in claim 1 , further comprising the step of identifying medical providers treating episodes treatment groups by identifying each episode treatment group by Primary Care Physician using the computer processor.