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  Systems and methods for assessing and optimizing healthcare administrationRelated Patent Categories: Data Processing: Financial, Business Practice, Management, Or Cost/price Determination, Automated Electrical Financial Or Business Practice Or Management Arrangement, Health Care Management (e.g., Record Management, Icda Billing)The Patent Description & Claims data below is from USPTO Patent Application 20060190295. Brief Patent Description - Full Patent Description - Patent Application Claims
CROSS-REFERENCE TO RELATED APPLICATIONS [0001] Not Applicable STATEMENT RE: FEDERALLY SPONSORED RESEARCH/DEVELOPMENT [0002] Not Applicable BACKGROUND OF THE INVENTION [0003] The present invention is directed to systems and methods for comprehensively assessing and optimizing the administration of healthcare as rendered by a group of physicians to a specific patient population. More particularly, the present invention comprises systems and methods that conserve medical resources utilized to care for the patient population, ensure uniformity in the procedures/tests utilized to render such care, identify and assess those patients afflicted with a chronic condition requiring high-cost healthcare, and provide means to continuously monitor and evaluate the quality of healthcare delivered. [0004] Essential to high quality and cost-effective health care is the proper diagnosis of a patient's condition. From a proper diagnosis, the appropriate medical attention utilized to treat the underlying condition, whether it be the performance of a medical procedure, laboratory tests and/or prescription of medication, can be determined. To that end, and as is well-known in the art, standard diagnoses codes are extensively utilized pursuant to conventional disease classification techniques that provide a quick, well-understood method to document medical care administered to a patient. Exemplarily of and perhaps most widely utilized of such formats is the International Classification of Diseases 9.sup.th Edition (ICD number 9) three digit codes. Likewise, with respect to the medical treatment that has been rendered, such procedures are typically referenced according to Current Procedural Terminology (CPT). Also frequently referenced in connection with the delivery of health care are drug codes (e.g., NDC), other service codes (e.g., HCPCS), among others. [0005] Notwithstanding such basic principles of medicine, as well as an infrastructure of coding practices to help facilitate the delivery of health care and documentation of patient treatment, the current administration of healthcare in the United States is subject to tremendous abuse and is grossly inefficient. In this regard, patients, healthcare providers and healthcare providing institutions often encourage wasteful practices that result in needless procedures and tests being performed. Moreover, healthcare providers and healthcare providing institutions, such as hospitals, clinical laboratories, outpatient and rehabilitation facilities, engage in capricious billing practices that enable such providers and institutions to charge for a multiplicity of services that may be available under a single clinical event that is typically identified by a single CPT code. [0006] Further problematic with such practice is that healthcare providers and healthcare providing institutions frequently utilize the wrong codes for diagnosis or otherwise use incorrect or multiple CPT codes to seek reimbursement, whether it be from an insurance company, health maintenance organization or government sponsored healthcare program, such as Medicare. In this regard, by failing to follow any type of uniform healthcare delivery system, and hence uniform coding practice commensurate therewith, results in overcharges for procedures that have been unnecessarily performed, improper diagnosis and duplicative and unnecessary tests and procedures. [0007] In addition to health care providers and institutions, patients themselves contribute substantially to the cost and ineffective utilization of health care resources. As is well-known, patients can and frequently do seek unnecessary medical treatment or otherwise attempt to influence the judgment of the health care provider by demanding that unnecessary tests or procedures be performed, that the patients have access to specialists or particular medications, and/or seek in-patient services in situations where the patient's clinical condition clearly does not justify such level of care. Such potential abuses are particularly likely where patients are allowed the discretion to directly access specialists, as is typical in several well-known health care insurance plans, such as Blue Cross and Blue Shield, which thus bypasses the critical role played by the primary care physician in making an initial assessment of a patient's condition and whether the same truly warrants the attention of a particular specialist, and not to mention the specialist best suited to handle a particular condition. [0008] Such conventional health care practices are particularly wasteful in the context of providing healthcare to patients afflicted with a chronic condition requiring aggressive medical management. Such conditions, known as high-cost chronic conditions, include cancer, cardiovascular disease, diabetes, HIV, liver disease and pulmonary disease, among several others. To treat such high-cost chronic conditions typically involves continuous patient treatment, which may take the form of a variety of medical procedures, tests, prescription medicines, and the like, as well as continuously monitoring the patient's condition to make sure that the underlying chronic condition does not develop to a more advance state, develop complications, and/or give rise to further related medical condition. Current practices, however, are ill suited to dynamically treat the progression of disease, and most physicians and healthcare institutions merely react to the patient's condition as opposed to be proactively involved in and anticipate the potential future needs of the patient. Such lack of responsiveness is typically reflected in the coding practices associated with the care delivered to the patient, which often times can be inaccurate and inappropriate based upon a general lack of patient history documentation and anticipated need to follow up with the patient. As a result of such poor practices, medical costs associated with the treatment of chronic conditions become astronomical and almost always beyond the capability of most individuals to pay. [0009] In order to counter such wasteful and abusive practices, attempts have been made to implement certain procedures to contain health care costs and conserve the utilization of health care resources. Exemplary of such attempts include requiring prior authorization and approval by an intermediate entity, such as a health maintenance organization or health insurance plan, to the extent a physician seeks to take a specified action, such as perform surgery, order a medical supply or refer the patient to a specialist. Also utilized are the practices of bundling, whereby a physician is paid a single payment for two or more medical services, and capitation whereby a health care provider is paid a set dollar amount as determined by a per member, per month calculation to deliver medical services to a specific patient population (i.e., members of a health maintenance organization). Still further examples include the use of preferred provider discounts, which encourage the use by patients of specific health care providers, and usual and customary reductions, which impose a reduction in the payment of medical services rendered as deemed justified by a health plan or insurance company based upon what is considered to be the justified value of such services as rendered in a particular geographical area. [0010] Despite such attempts, however, there has yet to be devised any type of health care administration system or method that substantially conserves utilization of health care resources that, as a consequence, can dramatically lower the costs associated with providing care to a specific patient population, especially in connection with the treatment of patients with high cost chronic conditions. Such attempts have likewise failed to maintain any degree of consistent quality of health care insofar as prior art cost containment practices have been and continue to be riddled with "loopholes" with insufficient cost-deterrent mechanisms necessary to conserve and optimally utilize a finite amount of health care resources to treat accurately diagnosed patients. [0011] As a result of the aforementioned abuses and inefficiencies associated with the utilization of health care resources, the cost of health care has and continues to increase substantially while the quality of the health care provided has not necessarily improved. As such, there is a substantial need in the art for a health care administration system and method that are operative to effectively and efficiently utilize health care resources to administer care to a patient population as compared to conventional practices. There is additionally a need for a healthcare administration system and method that utilizes a standardized coding practice that adheres to a standardized diagnosis treatment scheme that can be reviewed for accuracy and physician competency. There is still further a need in the art for such a system and method that is generally effective in eliminating the wasteful practices associated with the allocation and utilization of health care resources, especially in connection with the treatment of patients affected with chronic ailments, without adversely compromising clinical outcomes or quality of care. BRIEF SUMMARY OF THE INVENTION [0012] The present invention specifically addresses and alleviates the above-identified deficiencies in the art. In this regard, the present invention is directed to a comprehensive medical information and treatment system that is operative to compile, track and provide means for reviewing the administration of healthcare by a group of physicians and healthcare administration institutions to a specific patient population. In this respect, the present invention is operative to assess the appropriateness of each and every diagnosis, as well as the specific tests and procedures that have been ordered/rendered by a primary care physician to specific patients within the patient population. The system specifies, through a uniform coding procedure, each diagnosis and every test/procedure ordered/rendered by each physician for each patient such that a comprehensive medical history is compiled for each patient. The system further tracks each event for which medical care was rendered (claims history), the patient's case management, pharmacy information related to all medications prescribed to the patient, and any and all laboratory tests and results therefrom, including the specific dates that such procedures and tests were performed and medications prescribed. The compiled data will preferably be managed as electronic medical records accessible through a computer network, and in particular the Internet. [0013] From such compilation of data, an assessment is made according to standardized care criteria and coding practices whereby a specific physician can be assessed as to the appropriateness of the diagnosis made, as well as the care he or she has rendered based upon the specific procedures and tests that were rendered/ordered to the specific patients under his of her care. In this regard, it is contemplated that the competency and efficiency by which a specific physician practices medicine can be adjudged according to the appropriateness of the coding practices followed by the physician, which will correlate with the proper diagnosis and specific type of procedures and tests administered to specific patients on specific occasions. Along these lines, it is contemplated that a number of statistical analyses can be applied in reviewing the electronic medical records that are operative to assess potentially inappropriate coding practices, which are thus indicative of wasteful, unnecessary or sub-optimal healthcare. [0014] In addition to the foregoing compilation and assessment of healthcare as administered by a select group of physicians to a specific patient population, the system further integrates data related to the diagnosis and treatment associated with the care of patients within the patient population afflicted with high-cost chronic conditions, such as cancer, cardiovascular disease, diabetes, pulmonary disease or quadriplegia. The system is further particularly sensitive with respect to the treatment of high-cost chronic conditions in order to ensure that such chronic conditions have been properly diagnosed, whether further coding (indicative of further specific procedures and tests) may be warranted, whether additional coding is appropriate based upon additional related diagnoses based upon the current diagnosis (potential hierarchical review), and review to ensure that the treating physician has complied with all proper coding procedures indicative of the most cost-effective medical management practices coupled with the most favorable patient outcome. [0015] With regard to those patients that have been properly identified as being afflicted with a high-cost chronic condition, the system of the present invention is operative to separately compile data related thereto to thus enable those patients to be assessed based upon the type of condition and required long-term treatment necessary to secure the most favorable patient outcome. Additionally, such information associated with those members having a high-cost chronic condition can be utilized to develop cost-effective treatment strategies that may be custom tailored to provide an optimal patient treatment. [0016] In addition to the foregoing, it is further contemplated that by virtue of existing preferably in an electronic medical record format, the systems and methods of the present invention will be exceptionally useful in performing standardized electronic transactions as provided for in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. In this regard, such transactions, as set forth in HIPAA, expressly include claims, remittance and payment advice, claims status, enrollment and disenrollment in a health plan, premium payments, eligibility inquiries and responses, referral certifications and authorizations, coordination of benefits, and the like, all of which can be facilitated through use of the present invention according to a standardized transaction format, which can include the uniform use of codes typically associated with conventional billing practices, such as diagnosis codes mentioned above (i.e., ICDM-9-CM, CPT-4, NDC, and HCPCS). [0017] All of these objectives and more are accomplished by the present invention. BRIEF DESCRIPTION OF THE DRAWINGS [0018] These, as well as other features of the present invention, will become more apparent upon reference to the drawings wherein: [0019] FIG. 1 is a flowchart depicting the steps for practicing the present invention as it relates to administering and documenting healthcare administered by primary care physicians to a patient population, including healthcare administered to patients within the patient population afflicted with high-cost chronic conditions. Continue reading... Full patent description for Systems and methods for assessing and optimizing healthcare administration Brief Patent Description - Full Patent Description - Patent Application Claims Click on the above for other options relating to this Systems and methods for assessing and optimizing healthcare administration patent application. ###  How KEYWORD MONITOR works... a FREE service from FreshPatents1. Sign up (takes 30 seconds). 2. Fill in the keywords to be monitored. 3. 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