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US 2014/0278567 A1Published application
Determining reimbursement amounts based on reimbursement models
AssigneeMcKesson Financial Holdings
InventorsMichael Flanagan, Julian Klein, Vikram Anantha, Suresh Muppalla, Murali Karamchedu, Surya Suravarapu, Scott Edward Fraser
Life of this patent
Estimating the term…
Abstract
System, methods, and computer-readable media for determining allowed reimbursement amounts for one or more healthcare services rendered by a healthcare provider to a patient are disclosed. The allowed reimbursement amount may be determined in accordance with reimbursement model parameter(s) and/or reimbursement rule(s) associated with a reimbursement model.
Claims27
A method, comprising:
- identifying, by a reimbursement determination system comprising one or more computers, a reimbursement model;
- receiving, by the reimbursement determination system, input data comprising healthcare claim data associated with a healthcare claim, wherein the healthcare claim data comprises data identifying an insurance product offered by a payor and associated with a patient and data identifying a healthcare service rendered to the patient;
- determining, by the reimbursement determination system, that the insurance product is associated with the reimbursement model;
- determining, by the reimbursement determination system and based at least in part on the reimbursement model, a group of healthcare services associated with the insurance product, wherein the group of healthcare services comprises the healthcare service rendered to the patient;
- identifying, by the reimbursement determination system, at least one of:
- i) a set of one or more reimbursement model parameters associated with the group of healthcare services or ii) a set of one or more reimbursement rules associated with the group of healthcare services;
- and
- determining, by the reimbursement determination system and based at least in part on at least one of:
- i) the set of one or more reimbursement model parameters or ii) the set of one or more reimbursement rules, a reimbursement amount for the healthcare service rendered to the patient.
6 more elements
A system, comprising:
- at least one processor;
- and
- at least one memory storing computer-executable instructions,
- wherein the at least one processor is configured to access the at least one memory and execute the computer-executable instructions to:
- identify a reimbursement model;
- receive input data comprising healthcare claim data associated with a healthcare claim, wherein the healthcare claim data comprises data identifying an insurance product offered by a payor and associated with a patient and data identifying a healthcare service rendered to the patient;
- determine that the insurance product is associated with the reimbursement model;
- determine, based at least in part on the reimbursement model, a group of healthcare services associated with the insurance product, wherein the group of healthcare services comprises the healthcare service rendered to the patient;
- identify at least one of:
- i) a set of one or more reimbursement model parameters associated with the group of healthcare services or ii) a set of one or more reimbursement rules associated with the group of healthcare services;
- and
- determine, based at least in part on at least one of:
- i) the set of one or more reimbursement model parameters or ii) the set of one or more reimbursement rules, a reimbursement amount for the healthcare service rendered to the patient.
10 more elements
One or more computer-readable media storing computer-executable instructions that responsive to execution cause operations to be performed comprising:
- identifying a reimbursement model;
- receiving input data comprising healthcare claim data associated with a healthcare claim, wherein the healthcare claim data comprises data identifying an insurance product offered by a payor and associated with a patient and data identifying a healthcare service rendered to the patient;
- determining that the insurance product is associated with the reimbursement model;
- determining, based at least in part on the reimbursement model, a group of healthcare services associated with the insurance product, wherein the group of healthcare services comprises the healthcare service rendered to the patient;
- identifying at least one of:
- i) a set of one or more reimbursement model parameters associated with the group of healthcare services or ii) a set of one or more reimbursement rules associated with the group of healthcare services;
- and
- determining, based at least in part on at least one of:
- i) the set of one or more reimbursement model parameters or ii) the set of one or more reimbursement rules, a reimbursement amount for the healthcare service rendered to the patient.
6 more elements
Dependencies are inferred from the claim text.