Patent Issued for Methods, Apparatuses, And Systems For Deriving An Expected Emergency Department Visit Level (USPTO 10,417,382)

2019 SEP 27 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- Optum Inc. (Minnetonka, Minnesota, United States) has been issued patent number 10,417,382, according to news reporting originating out of Alexandria, Virginia, by NewsRx editors.

The patent’s inventors are Detolla, Michael J. (Issaquah, WA); Weintraub, Shannon L. (Woodinville, WA); Valente, Jr., Ernest (San Rafael, CA).

This patent was filed on July 28, 2017 and was published online on September 30, 2019.

From the background information supplied by the inventors, news correspondents obtained the following quote: “The inventors have discovered limitations with existing computerized processing of healthcare insurance claims including the identification of over-claimed or overcharged healthcare insurance claims. Through applied effort, ingenuity, and innovation, the inventors have solved many of these identified limitations by developing a solution that is embodied by the present invention and described in detail below.”

Supplementing the background information on this patent, NewsRx reporters also obtained the inventors’ summary information for this patent: “With the increasing cost of healthcare and healthcare related expenses there is an increasing drive to ensure that healthcare is paid for in a consistent and verified manner. For example, there may be institutional pressures to overcode (i.e., classify medical treatment as more severe or serious than it really is), which allows a healthcare provider to collect a larger payment for the medical treatment of a patient. Correcting this overcoding is important to healthcare claims payers, especially institutional payers such as insurance companies and the Centers for Medicare and Medicaid services (CMS), which pay for large amounts of healthcare expenses, and for whom cost savings in any level of healthcare service can result in large savings. The overcoding and subsequent overcharging of medical treatment is generally kept in check by strict coding guidelines maintained by CMS and AMA (American Medical Association) for most patient procedures and treatment. However, one area of claim coding that has less stringent guidelines is outpatient emergency department facility visit level evaluation and management (E/M) coding. In general, E/M coding classifies services into a level between 1 and 5 that are meant to be tied to resource usage of the emergency department facility. E/M coding thus provides compensation to the emergency department facility for the volume and intensity of the resources used that the healthcare facility is not otherwise compensated for in other ways (e.g., through the billing of lab tests or the like). In general, each emergency department facility is responsible for creating or adopting a set of guidelines, methods, and/or algorithms for E/M coding and is also required to apply its guidelines consistently. However, the flexibility of the E/M coding guidelines has led to a patchwork of national and ad hoc guidelines for E/M coding that has produced inconsistent and in many cases overcoded claims across different emergency department facilities.

“Indeed, payers like insurance companies and CMS have seen consistently increasing coding levels for emergency department visit levels despite not seeing a corresponding increase in the level of intensity required to treat patients. Thus, payers need a method to independently classify or code the E/M treatment which can be used to verify that the coded claims received from an emergency department facility actually reflect the acuity or intensity of each patient’s condition and treatment and accurately reflect the resource usage of the facility that treated the patient’s condition. Due to the large number of individual codes used to code claims and the large number of claims submitted to payers each day, manual examination of each of the submitted sets of claims for patient treatment would be impossible without large amounts of capital and labor that would itself introduce costs eliminating any cost savings a payer may see in correcting the coding of the overcoded claim sets. Moreover, human fallibility ensures that even the best managed staff would not be able to operate entirely consistently, and in any event, would not be able to guarantee an evaluation of every claim in near real time, and the introduction of human error and unreliability would further undercut the value of a human solution to this problem.

“As described herein, the inventors have developed a system and method for receiving and verifying that the claimed treatment codes from emergency departments accurately reflects the treatment (e.g. facility resource usages and intensity) provided to the patient by utilizing treatment codes that are highly standardized to derive an expected emergency department visit level (EEDVL) code.

“Accordingly, example methods, apparatuses, and computer program products described herein are designed to receive a set of healthcare claims for a patient’s visit to an emergency department; extract, from the set of healthcare claims, a set of treatment codes representing services performed during the emergency department visit and the condition of the patient; derive, using the set of treatment codes, a standard value, an extended value, and a patient complexity adjustment; and determine the EEDVL using the standard value, the extended value, and the patient complexity adjustment.

“In a first embodiment, a computer implemented method for deriving an expected emergency department visit level (EEDVL) is provided. The method comprises receiving, by communication circuitry of a computing device, a set of healthcare claims for a patient’s visit to an emergency department and extracting, by a claims evaluator module of the computing device and from the set of healthcare claims, a set of treatment codes representing services performed during the emergency department visit and the condition of the patient. The method also comprises deriving, by an EEDVL module of the computing device and using the set of treatment codes, a standard value, an extended value, and a patient complexity adjustment, and determining the EEDVL by the EEDVL module of the computing device and using the standard value, the extended value, and the patient complexity adjustment.

“In some embodiments, deriving the standard value also comprises identifying, by the EEDVL module of the computing device and from the set of treatment codes, one or more reasons for the patient’s visit, determining, by the EEDVL module of the computing device and from a standard value database, a patient complexity adjustment (PSCA) score for each of the one or more reasons for the patient’s visit, and deriving the standard value by the EEDVL module of the computing device and from the PSCA score.

“In some embodiments, deriving the extended value comprises identifying, by the EEDVL module of the computing device and from the set of treatment codes, one or more resource utilization codes for the patient visit, determining, by the EEDVL module of the computing device and from an extended value database, an extended value score for each of the one or more resource utilization codes, and deriving the extended value by the EEDVL module of the computing device and the extended value score.

“In some embodiments, deriving the extended value comprises summing the extended value scores for the one or more resource utilization codes.

“In some embodiments, deriving the patient complexity adjustment comprises identifying, by the EEDVL module of the computing device and from the set of treatment codes, one or more secondary codes for the patient visit, determining, by the EEDVL module of the computing device and from a patient complexity adjustment database, a secondary score from the one or more secondary codes, and deriving the patient complexity adjustment by the EEDVL module of the computing device and from the secondary score.

“In some embodiments, deriving the EEDVL comprises generating a final score by the EEDVL module of the computing device and based on the standard value, the extended value, and the patient complexity adjustment, and determining the EEDVL by the EEDVL module of the computing device and using the final score and a threshold table, wherein the threshold table comprises a set of threshold ranges corresponding to a set of emergency department visit levels, wherein the final score is within a particular threshold range of the set of threshold ranges, and wherein the EEDVL comprises the emergency department visit level corresponding to the particular threshold range.

“In some embodiments, the computer implemented method further comprises providing, by the communication circuitry of the computing device, a notification comprising the EEDVL to a claim source.

“In some embodiments, the computer implemented method further comprises identifying, by the claims evaluator module of the computing device and from the set of healthcare claims, a claimed emergency department visit level (CEDVL), and comparing, by the claims evaluator module of the computing device, the CEDVL with the EEDVL to determine whether the CEDVL comprises a higher or lower level than the EEDVL.

“In some embodiments, in an instance in which the CEDVL comprises a higher or lower level than the EEDVL, the method further comprises providing, by the communication circuitry of the computing device, the notification to a claim source, wherein the notification comprises one or more of: a notification that the CEDVL is higher or lower than the EEDVL, or a notification the EEDVL will be used in a claims payout instead of the CEDVL.

“In another embodiment, an apparatus for deriving an expected emergency department visit level (EEDVL) is provided. The apparatus comprising communication circuitry configured to receive a set of healthcare claims for a patient’s visit to an emergency department. The apparatus also comprises a claims evaluator module configured to extract, from the set of healthcare claims, a set of treatment codes representing services performed during the emergency department visit and the condition of the patient. The apparatus also comprising an EEDVL module configured to derive, using the set of treatment codes, a standard value, an extended value, and a patient complexity adjustment, and determine, using the standard value, the extended value, and the patient complexity adjustment, the EEDVL.

“In some embodiments, in order to derive the standard value the EEDVL module is further configured to identify, from the set of treatment codes, one or more reasons for the patient’s visit, determine, from a standard value database, a patient complexity adjustment (PSCA) score for each of the one or more reasons for the patient’s visit, and derive the standard value from the PSCA score.

“In some embodiments, in order to derive the extended value the EEDVL module is further configured to identify, from the set of treatment codes, one or more resource utilization codes for the patient visit, determine from an extended value database, an extended value score for each of the one or more resource utilization codes, and derive from the extended value scores, the extended value.

“In some embodiments, in order to derive the extended value the EEDVL module is further configured to sum the extended value scores for the one or more resource utilization codes.

“In some embodiments, in order to derive the patient complexity adjustment the EEDVL module is further configured to identify, from the set of treatment codes, one or more secondary codes for the patient visit, determine, from a patient complexity adjustment database, a secondary score from the one or more secondary codes, and derive, from the secondary score, the patient complexity adjustment.

“In some embodiments, in order to derive the EEDVL the EEDVL module is further configured to generate a final score based on the standard value, the extended value, and the patient complexity adjustment, and determine the EEDVL using the final score and a threshold table, wherein the threshold table comprises a set of thresholds ranges corresponding to a set of emergency department visit levels, wherein the final score is within a particular threshold range of the set of threshold ranges, and wherein the EEDVL comprises the emergency department visit level corresponding to the particular threshold range.

“In some embodiments, the communication circuitry is further configured to provide a notification to a claim source comprising the EEDVL.

“In some embodiments, the claims evaluator module is further configured to identify from the set of healthcare claims, a claimed emergency department visit level (CEDVL), and compare the CEDVL with the EEDVL to determine whether the CEDVL comprises a higher or lower level than the EEDVL.

“In some embodiments, in an instance in which the CEDVL comprises a higher or lower level than the EEDVL, the communication circuitry is further configured to provide the notification to the claim source, wherein the notification comprises one or more of: a notification that the CEDVL is higher or lower than the EEDVL, or a notification the EEDVL will be used in a claims payout instead of the CEDVL.

“In another example embodiment, a non-transitory computer-readable storage medium for healthcare provider network assessment is provided. The non-transitory computer-readable storage medium storing program code instructions that, when executed, cause a computing device to receive a set of healthcare claims for a patient’s visit to an emergency department, extract, from the set of healthcare claims, a set of treatment codes representing services performed during the emergency department visit and the condition of the patient, derive, using the set of treatment codes, a standard value, an extended value, and a patient complexity adjustment, and determine the EEDVL using the standard value, the extended value, and the patient complexity adjustment.

“In some embodiments, the program code instructions, when executed, further cause the computing device to: identify, from the set of treatment codes, one or more reasons for the patient’s visit; determine, from a standard value database, a patient complexity adjustment (PSCA) score for each of the one or more reasons for the patient’s visit; derive the standard value from the PSCA scores, identify, from the set of treatment codes, one or more resource utilization codes for the patient visit; determine from an extended value database, an extended value score for each of the one or more resource utilization codes; derive from the extended value scores, the extended value, identify, from the set of treatment codes, one or more secondary codes for the patient visit; determine, from a patient complexity adjustment database, a secondary score from the one or more secondary codes, derive, from the secondary score, the patient complexity adjustment; generate a final score based on the standard value, the extended value, and the patient complexity adjustment; and determine the EEDVL using the final score and a threshold table, wherein the threshold table comprises a set of thresholds ranges corresponding to a set of emergency department visit levels, wherein the final score is within a particular threshold range of the set of threshold ranges, and wherein the EEDVL comprises the emergency department visit level corresponding to the particular threshold range.

“The above summary is provided merely for purposes of summarizing some example embodiments to provide a basic understanding of some aspects of the invention. Accordingly, it will be appreciated that the above described embodiments are merely examples and should not be construed to narrow the scope or spirit of the invention in any way. It will be appreciated that the scope of the invention encompasses many potential embodiments in addition to those here summarized, some of which will be further described below.”

The claims supplied by the inventors are:

“What is claimed is:

“1. A computer implemented method for deriving an expected emergency department visit level (EEDVL), the EEDVL comprising an expected medical claims coding level, the method comprising: receiving, by one or more processors, a set of healthcare claims for a patient’s visit to an emergency department, wherein the set of healthcare claims comprises a claimed emergency department visit level (CEDVL), the CEDLV comprising a claimed medical claims coding level; extracting, by the one or more processors from the set of healthcare claims, a set of treatment codes indicative of (a) services performed during the patient’s visit to the emergency department, and (b) one or more conditions associated with the patient’s visit to the emergency department; deriving, by the one or more processors, a standard value by: automatically identifying, based at least in part on the set of treatment codes, data indicative of one or more reasons for the patient’s visit to the emergency department, automatically determining, based at least in part on the one or more reasons for the patient’s visit to the emergency department and using a standard value lookup table, a patient complexity adjustment (PSCA) score, and automatically deriving, based at least in part on the PSCA score, the standard value for the patient’s visit to the emergency department, wherein the standard value comprises a standard resource valuation; deriving, by the one or more processors and based at least in part on the set of treatment codes, an extended value indicative of resource utilization during the patient’s visit to the emergency department; deriving, by the one or more processors and based at least in part on the set of treatment codes, a patient complexity adjustment by: automatically identifying, based at least in part on the set of treatment codes, one or more secondary codes for the patient’s visit to the emergency department, automatically determining, using a patient complexity adjustment lookup table, a secondary score based at least in part on the one or more secondary codes, and automatically deriving, based at least in part on the secondary score, the patient complexity adjustment; determining the EEDVL, by the one or more processors and based at least in part on the standard value, the extended value, and the patient complexity adjustment; comparing, by the one or more processors, the CEDVL and the EEDVL to determine if the CEDVL and the EEDVL are different; and responsive to a determination that the CEDVL and the EEDVL are different, automatically (a) generating a notification comprising the CEDVL and the EEDVL, and (b) automatically transmitting the notification to a user account associated with the CEDVL.

“2. The computer implemented method of claim 1, wherein deriving the extended value comprises: identifying one or more resource utilization codes for the patient visit; determining an extended value score for each of the one or more resource utilization codes; and deriving, from the extended value scores, the extended value.

“3. The computer implemented method of claim 1, wherein deriving the extended value comprises summing the extended value scores for the one or more resource utilization codes.

“4. The computer implemented method of claim 1, wherein deriving the EEDVL comprises: generating a final score based on the standard value, the extended value, and the patient complexity adjustment; and determining the EEDVL using the final score and a threshold table, wherein the threshold table comprises a set of threshold ranges corresponding to a set of emergency department visit levels, wherein the final score is within a particular threshold range of the set of threshold ranges, and wherein the EEDVL comprises the emergency department visit level corresponding to the particular threshold range.

“5. A healthcare claim payer apparatus for deriving an expected emergency department visit level (EEDVL), the EEDVL comprising an expected medical claims coding level, the apparatus configured to: receive a set of healthcare claims for a patient’s visit to an emergency department, wherein the set of healthcare claims comprises a claimed emergency department visit level (CEDVL) the CEDLV comprising a claimed medical claims coding level; extract, from the set of healthcare claims, a set of treatment codes indicative of (a) services performed during the patient’s visit to the emergency department, and (b) one or more conditions associated with the patient’s visit to the emergency department; derive a standard value by: automatically identifying, based at least in part on the set of treatment codes, data indicative of one or more reasons for the patient’s visit to the emergency department, automatically determining, based at least in part on the one or more reasons for the patient’s visit to the emergency department and using a standard value lookup table, a patient complexity adjustment (PSCA) score for each of the one or more reasons for the patient’s visit, and automatically deriving, based at least in part on the PSCA score, the standard value for the patient’s visit to the emergency department, wherein the standard value comprises a standard resource valuation; derive, based at least in part on the set of treatment codes, an extended value indicative of resource utilization during the patient’s visit to the emergency department; derive, based at least in part on the set of treatment codes, a patient complexity adjustment by: automatically identifying, based at least in part on the set of treatment codes, one or more secondary codes for the patient’s visit to the emergency department, automatically determining, using a patient complexity adjustment lookup table, a secondary score based at least in part on the one or more secondary codes, and automatically deriving, based at least in part on the secondary score, the patient complexity adjustment; determine the EEDVL, based at least in part on the standard value, the extended value, and the patient complexity adjustment; compare the CEDVL and the EEDVL to determine if the CEDVL and the EEDVL are different; and responsive to a determination that the CEDVL and the EEDVL are different, automatically (a) generate a notification comprising the CEDVL and the EEDVL, and (b) automatically transmit the notification to a user account associated with the CEDVL.

“6. The apparatus of claim 5, wherein to derive the extended value the apparatus is further configured to: identify, from the set of treatment codes, one or more resource utilization codes for the patient visit; determine, by using an extended value lookup table, an extended value score for each of the one or more resource utilization codes; and derive, from the extended value scores, the extended value.

“7. The apparatus of claim 6, wherein to derive the extended value the EEDVL module is further configured to sum the extended value scores for the one or more resource utilization codes.

“8. The apparatus of claim 5, wherein the apparatus is further configured to: generate a final score based on the standard value, the extended value, and the patient complexity adjustment; and determine the EEDVL using the final score and a threshold table, wherein the threshold table comprises a set of thresholds ranges corresponding to a set of emergency department visit levels, wherein the final score is within a particular threshold range of the set of threshold ranges, and wherein the EEDVL comprises the emergency department visit level corresponding to the particular threshold range.

“9. A non-transitory computer-readable storage medium for deriving an expected emergency department visit level (EEDVL), the EEDVL comprising an expected medical claims coding level, the non-transitory computer-readable storage medium storing program code instructions that, when executed, cause a healthcare claim payer computing device to: receive a set of healthcare claims for a patient’s visit to an emergency department, wherein the set of healthcare claims comprises a claimed emergency department visit level (CEDVL), the CEDLV comprising a claimed medical claims coding level; extract, from the set of healthcare claims, a set of treatment codes indicative of (a) services performed during the patient’s visit to the emergency department, and (b) one or more conditions associated with the patient’s visit to the emergency department; derive a standard value by: automatically identifying, based at least in part on the set of treatment codes, data indicative of one or more reasons for the patient’s visit to the emergency department, automatically determining, based at least in part on the one or more reasons for the patient’s visit to the emergency department and using a standard value lookup table, a patient complexity adjustment (PSCA) score for each of the one or more reasons for the patient’s visit, automatically deriving, based at least in part on the PSCA score, the standard value for the patient’s visit to the emergency department, wherein the standard value comprises a standard resource valuation; derive, based at least in part on the set of treatment codes, an extended value indicative of resource utilization during the patient’s visit to the emergency department; derive, based at least in part on the set of treatment codes, a patient complexity adjustment by: automatically identifying, based at least in part on the set of treatment codes, one or more secondary codes for the patient’s visit to the emergency department, automatically determining, using a patient complexity adjustment lookup table, a secondary score based at least in part on the one or more secondary codes, and automatically deriving, based at least in part on the secondary score, the patient complexity adjustment; determine the EEDVL, based at least in part on the standard value, the extended value, and the patient complexity adjustment; compare the CEDVL and the EEDVL to determine if the CEDVL and the EEDVL are different; and responsive to a determination that the CEDVL and the EEDVL are different, automatically (a) generate a notification comprising the CEDVL and the EEDVL, and (b) automatically transmit the notification to a user account associated with the CEDVL.

“10. The method of claim 1, further comprising: determining a payout for the healthcare claims using the EEDVL; and transmitting a payment to the healthcare provider based on the determined payout.

“11. The apparatus of claim 5, further comprising an adjudication module configured to: determine a payout for the healthcare claims using the EEDVL; and transmit a payment to the healthcare provider based on the determined payout.”

For the URL and additional information on this patent, see: Detolla, Michael J.; Weintraub, Shannon L.; Valente, Jr., Ernest. Methods, Apparatuses, And Systems For Deriving An Expected Emergency Department Visit Level. U.S. Patent Number 10,417,382, filed July 28, 2017, and published online on September 30, 2019. Patent URL: http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=10,417,382.PN.&OS=PN/10,417,382RS=PN/10,417,382

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