System and method for intelligent management of medical care
AssigneeThe Callas Group, LLC
InventorConstantine Callas
Life of this patent
Estimating the term…
Abstract
A computerized medical care system provides validation of a diagnosis of a medical condition and requested medical services for treating the medical condition. The medial care system invokes multiple filters to determine the appropriateness of the diagnosis and medical service. Real time feedback is provided based on the determination. If the medical care cannot be validated, the feedback includes the reasons for the failure to validate, and any supporting materials for the lack of validation. The feedback may also prompt the requesting entity to provide additional information to help support the medical provider's position as to why the requested medical care is appropriate.
Claims22
A data processing apparatus adapted for providing medical pre-approval, the data processing apparatus comprising:
- a processor;
- and
- a memory coupled to the processor and having program instructions stored therein, the processor being operable to execute the program instructions, the program instructions including:
- providing a first interface option for identifying a first code for a diagnosed condition;
- providing a second interface option for identifying a second code for a proposed medical service for the diagnosed condition;
- providing a third interface option for identifying a proposed charge amount for the proposed medical service;
- receiving a request for medical pre-approval, the request including the first code for the diagnosed condition, the second code for the proposed medical service, and the proposed charge amount;
- retrieving historical data of past charge amounts stored in a data store for the proposed medical service;
- identifying a reasonableness value based on the historical data of past charge amounts, wherein the identified reasonableness value is configured to be traced to a specific past charge amount stored in the data store for a specific provider for the proposed medical service performed for a specific patient;
- comparing the proposed charge amount against the identified reasonableness value;
- determining whether the proposed charge amount is presumptively reasonable or unreasonable based on the comparison of the proposed charge amount against the identified reasonableness value;
- if the proposed charge amount is determined to be presumptively reasonable based on the comparison, providing information indicative of pre-approval of the proposed medical service or charge;
- and
- if the proposed charge amount is determined to be presumptively unreasonable based on the comparison, prompting submission of information justifying the proposed charge amount.
A non-transitory computer readable media embodying program instructions for execution by a data processing apparatus, the program instructions adapting the data processing apparatus for providing medical pre-approval, the program instructions comprising:
- providing a first interface option for identifying a first code for a diagnosed condition;
- providing a second interface option for identifying a second code for a proposed medical service for the diagnosed condition;
- providing a third interface option for identifying a proposed charge amount for the proposed medical service;
- receiving a request for medical pre-approval, the request including the first code for the diagnosed condition, the second code for the proposed medical service, and the proposed charge amount;
- retrieving historical data of past charge amounts stored in a data store for the proposed medical service;
- identifying a reasonableness value based on the historical data of past charge amounts, wherein the identified reasonableness value is configured to be traced to a specific past charge amount stored in the data store for a specific provider for the proposed medical service performed for a specific patient;
- comparing the proposed charge amount against the identified reasonableness value;
- determining whether the proposed charge amount is presumptively reasonable or unreasonable based on the comparison of the proposed charge amount against the identified reasonableness value;
- if the proposed charge amount is determined to be presumptively reasonable based on the comparison, providing information indicative of pre-approval of the proposed medical service or charge;
- and
- if the proposed charge amount is determined to be presumptively unreasonable based on the comparison, prompting submission of information justifying the proposed charge amount.
Dependencies are inferred from the claim text.