US 11,455,690 B2Granted

Payer provider connect engine

AssigneeVvc Holding Corporation

InventorsRobert Maddison, Eric Rose, Donna Maddox, Saana Aldridge

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Abstract

Systems, methods and computer program products to identify and close gaps in care are provided. Aspects of the present disclosure disclosed and described herein enable a payer may identify gaps in care based on information in the payer database. The payer can send this information to the provider prior to patient scheduling. The scheduling system at the provider can use this information to schedule patients and their medical needs (e.g., medical test, lab tests, imaging tests, etc.) before the next patient appointment. Primary care providers (PCPs) can then be made aware of the gaps in care information, as well as Hierarchical Condition Category (HCC) coding gap information, so they can perform a complete diagnosis using all available clinical data. PCP notes along with the treatment the patient receives can be combined with the RAF (Risk Adjustment Score) shared by the payers to ensure patient is assessed for all relevant conditions during the visit. Payers can then be informed electronically that the gap in care has been closed; the payer can also receive the resultant claims such that correct RAF scores can be computed and HCC coding gaps can be closed.

Claims18

Dependent claims

A payer provider connectivity apparatus, the apparatus comprising:

a connect engine in communication with a first payer system, a second payer system, and a plurality of provider systems via a network, the connect engine to receive, via the network, medical codes including a first code from the first payer system corresponding to a patient and a second code from the second payer system corresponding to the patient;
the connect engine including:
a database to store the medical codes and instructions for execution;
and
a processor to execute the instructions to at least:
transform the medical codes to a common format, the common format to standardize the first code with the second code to determine a coding gap of the patient, wherein the coding gap is indicative of a gap in care of the patient;
and
when the connect engine determines the coding gap of the patient:
reconcile the coding gap with a scheduling gap of the patient to schedule an appointment to address the gap in care of the patient, wherein the scheduling gap is indicative of an available time for a provider to remedy the gap in care for the patient;
and
a plurality of smart agents including at least a first smart agent structured to be deployed to a first provider system and a second smart agent structured to be deployed to a second provider system of the plurality of provider systems to enable communication between the first and second provider systems, at least one of the first payer system or the second payer system, and the connect engine, the first smart agent and the second smart agent further structured to process data related to the coding gap when deployed at the respective first provider system and the second provider system, the first smart agent and the second smart agent in communication with the connect engine to:
reconcile and remove the coding gap from the database corresponding to the patient;
compute a risk adjustment score with at least one of the first payer system or the second payer system based on a claim diagnosis code triggered by removal of the coding gap;
and
coordinate the appointment scheduled for the patient based on the removal of the gap in care of the patient and the risk adjustment score.

12 more elements

A method comprising:

communicating, via a network using a connect engine including a processor, with a first payer system, a second payer system, and a plurality of provider systems, the connect engine to receive, via the network, medical codes including a first code from the first payer system corresponding to a patient and a second code from the second payer system corresponding to the patient;
storing, in a database using the connect engine, the medical codes and instructions for execution;
transforming, using the connect engine, the medical codes to a common format, the common format to standardize the first code with the second code to determine a coding gap of the patient, wherein the coding gap is indicative of a gap in care of the patient;
removing, using at least a first smart agent structured to be deployed to a first provider system and a second smart agent structured to be deployed to a second provider system of the plurality of provider systems to enable communication between the first and second provider systems, at least one of the first payer system or the second payer system, and the connect engine, the coding gap from the database corresponding to the patient, the first smart agent and the second smart agent further structured to process data related to the coding gap when deployed at the respective first provider system and the second provider system;
computing, using the respective smart agent, a risk adjustment score with at least one of the first payer system or the second payer system based on a claim diagnosis code triggered by removal of the coding gap;
and
coordinating the appointment scheduled for the patient, using the respective smart agent, with the connect engine based on removal of the gap in care of the patient and the risk adjustment score.

4 more elements

A non-transitory computer readable storage medium comprising instructions that, when executed, cause at least one processor to at least:

communicate, via a network using a connect engine, with a first payer system, a second payer system, and a plurality of provider systems, the connect engine to receive, via the network, medical codes including a first code from the first payer system corresponding to a patient and a second code from the second payer system corresponding to the patient;
store, in a database, the medical codes and instructions for execution;
transform the medical codes to a common format, the common format to standardize the first code with the second code to determine a coding gap of the patient, wherein the coding gap is indicative of a gap in care of the patient;
reconcile, when the processor determines the coding gap of the patient, the coding gap with a scheduling gap of the patient to schedule an appointment to address the gap in care of the patient, wherein the scheduling gap is indicative of an available time for a provider to remedy the gap in care for the patient;
remove, using at least a first smart agent structured to be deployed to a first provider system and a second smart agent structured to be deployed to a second provider system of the plurality of provider systems to enable communication between the first and second provider systems, at least one of the first payer system or the second payer system, and the connect engine, the coding gap from the database corresponding to the patient, the first smart agent and the second smart agent further structured to process data related to the coding gap when deployed at the respective first provider system and the second provider system;
compute, using the respective smart agent, a risk adjustment score with at least one of the first payer system or the second payer system based on a claim diagnosis code triggered by removal of the coding gap;
and
coordinate the appointment scheduled for the patient, using the respective smart agent, with the connect engine based on removal of the gap in care of the patient and the risk adjustment score.

5 more elements

Dependencies are inferred from the claim text.

Facts

Application: 15/195,080Filed 28 Jun 2016
Published: US 2017/0372430 A128 Dec 2017
Granted: 27 Sep 2022
Term ends: Not estimatedThe source records don’t support an estimate.

Classification7 codes

G06Q 40/08
Finance; Insurance; Tax strategies; Processing of corporate or income taxes: insurance
G16H 10/40
ICT specially adapted for the handling or processing of patient-related medical or healthcare data: for data related to laboratory analysis, e.g.…
G16H 10/60
ICT specially adapted for the handling or processing of patient-related medical or healthcare data: for patient-specific data, e.g. for electronic…
G16H 30/20
ICT specially adapted for the handling or processing of medical images: for handling medical images, e.g. DICOM, HL7 or PACS