Patent Issued for Matching healthcare groups and systems based on billed claims (USPTO 11562327): Milliman Solutions LLC

2023 FEB 09 (NewsRx) -- By a News Reporter-Staff News Editor at Hospital & Nursing Home Daily -- According to news reporting originating from Alexandria, Virginia, by NewsRx journalists, a patent by the inventors Muhlestein, David (Salt Lake City, UT, US), Richards, Robert (Salt Lake City, UT, US), filed on July 17, 2020, was published online on January 24, 2023.

The assignee for this patent, patent number 11562327, is Milliman Solutions LLC (Seattle, Washington, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “The healthcare industry is extraordinarily complex. Specifically, in the United States, relationships between healthcare practitioners, clinics, facilities, groups, and systems are complex and interwoven such that it can be challenging to identify relationships between different entities. One practitioner may see patients that are part of different systems, health insurance networks, or groups. Further, the practitioner may be associated with more than one facility or clinic. The interwoven relationships between healthcare entities makes it challenging to determine if a certain practitioner is associated with or employed by a certain facility, clinic, group, or system. Additionally, other relationships between practitioners, facilities, clinics, groups, and systems throughout the healthcare industry are difficult to identify and quantify.

“In some instances, it is necessary or beneficial to understand the relationships between healthcare entities. For example, a health insurance provider seeking to create an in-network selection of providers may need to know which practitioners are associated with which facilities, clinics, groups, or systems. Further for example, a manufacturer or seller of medical devices or pharmaceuticals may benefit from understanding the business relationships between practitioners, facilities, clinics, groups, and systems. In some instances, for example, the manufacturer or seller may sell a medical device or pharmaceutical to a single group, and this would in turn lead to distribution of that medical device or pharmaceutical to hundreds of practitioners associated with the group. These relationships between healthcare entities are nearly impossible to identify or quantify.

“In light of the foregoing, disclosed herein are systems, methods, and devices for identifying relationships between healthcare entities.”

In addition to obtaining background information on this patent, NewsRx editors also obtained the inventors’ summary information for this patent: “Disclosed herein are systems, methods, and devices for calculating cohesion metrics between healthcare entities. Specifically, disclosed herein are means for measuring the cohesion of practitioners that practice at healthcare clinics and groups and further for measuring the cohesion of practitioners performing procedures at healthcare facilities and systems. Additionally, disclosed herein are means for quantifying the cohesion of practitioners who have been captured by or are employed by a healthcare facility or system. Additionally, disclosed herein are means for linking healthcare procedure billing entities with office billing entities based on billed claims.

“Current understanding of the healthcare industry in the United States is extremely fragmented. In some instances, it is difficult or impossible to identify systems of care including financial, employment, and enrollment relationships between healthcare entities. The healthcare industry uses multiple data sources for storing billing, procedure, and facility records. There is no one data source that is ideal or reliable for identifying the numerous relationships between healthcare entities. Because healthcare data is fragmented, it can be beneficial to match different types of healthcare data. The matched data can be assessed to identify and quantify relationships between different entities.

“Embodiments of the disclosure leverage multiple data sources to describe relationships precisely and completely between healthcare entities. Relationships between practitioners and other healthcare entities cannot be viewed as binary. There are multiple types of affiliations between healthcare entities, and each affiliation may be characterized in terms of its strength. An affiliation reported as merely binary (i.e. yes/no, exists/does not exist, and so forth) masks important information.

“Embodiments of the disclosure begin at the level of individual practitioner billing and procedure codes and build from there to identify and quantify relationships between other healthcare entities. By tracking the relationships of individual practitioners to higher level entities, the connections between practitioners and multiple other entities can be identified. This is an improved and more streamlined method when compared with viewing all organizations as discrete, mutually exclusive sets of practitioners.

“Embodiments of the disclosure interpret affiliation metrics based on an individualized perspective. For example, a physician’s affiliation with a hospital has two perspectives: the physician’s perspective and the hospital’s perspective. The physician may view the hospital as a necessary portion of the practice that enables the physician to perform certain procedures. The hospital may view the physician as one of many, and the physician’s procedures performed at the hospital may represent a very small portion of all procedures performed at the hospital. Understanding affiliations from both perspectives is more informative than viewing the affiliations from only one perspective.”

The claims supplied by the inventors are:

“1. A method comprising: aggregating data from a plurality of different data sources, wherein the data comprises raw carrier claims data processed over a time period; translating the data retrieved from the plurality of different data sources to a common data format; cleaning the raw carrier claims data by removing superfluous data from the raw carrier claims data to generate cleaned data, wherein the raw carrier claims data is cleaned prior to being stored on a relational database; generating an intermediary file within the relational database that comprises the cleaned data; linking the relational database to a database platform that is accessible to a user by way of a user interface, and wherein the database platform is built on modeled data sources rather than raw data sources; assessing the intermediary file by way of the database platform to identify one or more office practitioners billing carrier claims comprising a certain office billing identifier; identifying one or more procedure practitioners associated with facility claims for procedures performed under a certain procedure billing identifier; identifying a common practitioner billing carrier claims comprising the certain office billing identifier and associated with facility claims for procedures performed under the certain procedure billing identifier; and generating an office-procedure pair by matching the certain office billing identifier with the certain procedure billing identifier based on an existence of the common practitioner: wherein the superfluous data comprise data that is not necessary for generating the office-procedure pair.

“2. The method of claim 1, further comprising calculating a proportion of procedures performed under the certain procedure billing identifier that were performed by the one or more office practitioners billing carrier claims comprising the certain office billing identifier.

“3. The method of claim 1, further comprising calculating a proportion of carrier claims billed under the certain office billing identifier that were performed by the one or more procedure practitioners associated with facility claims for procedures performed under the certain procedure billing identifier.

“4. The method of claim 1, wherein the certain procedure billing identifier is a system identifier associated with a healthcare system, and wherein the method further comprises: calculating a system billing affiliation metric for the common practitioner based on: total facility claims associated with the common practitioner performed at any of a plurality of healthcare systems over a time period; and total facility claims associated with the common practitioner performed at the healthcare system over the time period; and calculating a weighted procedure metric for the common practitioner by weighting a number of procedures performed by the common practitioner at the healthcare system.

“5. The method of claim 1, further comprising: determining an individual National Provider Identifier (NPI) for each of the one or more office practitioners; and determining an individual NPI for each of the one or more procedure practitioners; wherein identifying the common practitioner comprises identifying a unique individual NPI listed on carrier claims billed under the certain office billing identifier and also listed on facility claims for procedures performed under the certain procedure billing identifier.

“6. The method of claim 1, wherein identifying the common practitioner comprises determining there is the unique individual NPI listed on one or more carrier claims comprising the certain office billing identifier and also listed on one or more facility claims for procedures performed under the certain procedure billing identifier.

“7. The method of claim 1, further comprising: calculating a capture by the certain office billing identifier of procedures performed under the certain procedure billing identifier based on a sum of squared shares of procedures performed under the certain procedure billing identifier by the one or more office practitioners; or calculating a capture by the certain procedure billing identifier for claims billed under the certain office billing identifier based on a sum of squared shares of carrier claims billed under the certain office billing identifier by the one or more procedure practitioners.

“8. The method of claim 1, wherein the certain procedure billing identifier is a facility identifier associated with a healthcare facility, and wherein the method further comprises: calculating a facility billing affiliation metric for the common practitioner based on: total facility claims associated with the common practitioner performed at any of a plurality of healthcare facilities over a time period; and total facility claims associated with the common practitioner performed at the healthcare facility over the time period; and calculating a weighted procedure metric for the common practitioner by weighting a number of procedures performed by the common practitioner at the healthcare facility.

“9. The method of claim 1, wherein the certain office billing identifier is a clinic identifier associated with a healthcare clinic, and wherein the method further comprises: calculating a clinic billing affiliation metric for the common practitioner based on: total carrier claims billed by the common practitioner over a time period; and total carrier claims billed by the common practitioner comprising the clinic identifier over the time period; and calculating a weighted office metric for the common practitioner by weighting a number of carrier claims billed by the common practitioner at the healthcare clinic.

“10. The method of claim 1, further comprising executing an electronic data security measure with the relational database, wherein the electronic data security measure comprises one or more of securely communicating with a virtual datacenter associated with the database or de-encrypting encrypted data received from the database.

“11. A system comprising one or more processors configurable to execute instructions stored in non-transitory computer readable storage media, the instructions comprising: aggregating data from a plurality of different data sources, wherein the data comprises raw carrier claims data processed over a time period; cleaning the raw carrier claims data by removing superfluous data to generate cleaned data, wherein the raw carrier claims data is cleaned prior to being stored on a relational database; generating an intermediary file within the relational database that comprises the cleaned data; linking the relational database to a database platform that is accessible to a user by way of a user interface, and wherein the database platform is built on modeled data sources rather than raw data sources; assessing the intermediary file by way of the database platform to identify one or more office practitioners billing carrier claims comprising a certain office billing identifier; identifying one or more procedure practitioners associated with facility claims for procedures performed under a certain procedure billing identifier; identifying a common practitioner billing carrier claims comprising the certain office billing identifier and associated with facility claims for procedures performed under the certain procedure billing identifier; and generating an office-procedure pair by matching the certain office billing identifier with the certain procedure billing identifier based on an existence of the common practitioner; wherein the superfluous data comprise data that is not necessary for generating the office-procedure pair.

“12. The system of claim 11, wherein the instructions further comprise calculating a proportion of procedures performed under the certain procedure billing identifier that were performed by the one or more office practitioners billing carrier claims comprising the certain office billing identifier.

“13. The system of claim 11, wherein the instructions further comprise calculating a proportion of carrier claims billed under the certain office billing identifier that were performed by the one or more procedure practitioners associated with facility claims for procedures performed under the certain procedure billing identifier.

“14. The system of claim 11, wherein the certain procedure billing identifier is a system identifier associated with a healthcare system, and wherein the instructions further comprise: calculating a system billing affiliation metric for the common practitioner based on: total facility claims associated with the common practitioner performed at any of a plurality of healthcare systems over a time period; and total facility claims associated with the common practitioner performed at the healthcare system over the time period; and calculating a weighted procedure metric for the common practitioner by weighting a number of procedures performed by the common practitioner at the healthcare system.

“15. The system of claim 11, wherein the instructions further comprise: determining an individual National Provider Identifier (NPI) for each of the one or more office practitioners; and determining an individual NPI for each of the one or more procedure practitioners; wherein identifying the common practitioner comprises identifying a unique individual NPI listed on carrier claims billed under the certain office billing identifier and also listed on facility claims for procedures performed under the certain procedure billing identifier.

“16. The system of claim 11, wherein the instructions are such that identifying the common practitioner comprises determining there is the unique individual NPI listed on one or more carrier claims comprising the certain office billing identifier and also listed on one or more facility claims for procedures performed under the certain procedure billing identifier.”

There are additional claims. Please visit full patent to read further.

For more information, see this patent: Muhlestein, David. Matching healthcare groups and systems based on billed claims. U.S. Patent Number 11562327, filed July 17, 2020, and published online on January 24, 2023. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(11562327)&db=USPAT&type=ids

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