Researchers Submit Patent Application, “Systems And Methods For Determination Of Patient True State For Risk Management”, for Approval (USPTO 20200251207)
2020 AUG 21 (NewsRx) -- By a
The patent’s assignee is
News editors obtained the following quote from the background information supplied by the inventors: “The present invention relates generally to systems and methods for determination of patient true state using automated first pass review of patient medical records. Knowledge of the true state of a patient (determination of patient condition) enables management of coding risks, as well as enhanced patient management and record retention abilities. Some embodiments of the present systems and methods enable more accurate and rapid capture of MediCare eligible conditions, thereby ensuring providers are more fairly compensated, and ensure that medical records more accurately reflect a patient’s condition.
“Despite rapid growth of innovation in other fields in recent decades, the world of medical information, including patient medical records, billing, referrals, and a host of other information, has enjoyed little to no useful consolidation, reliability, or ease-of-access, leaving medical professionals, hospitals, clinics, and even insurance companies with many issues, such as unreliability of medical information, uncertainty of diagnosis, lack of standard, and a slew of other related problems.
“One common problem with the analysis of medical records is that identification of clinically pertinent conditions is often not properly identified, and further, even when identified, the evidence in the patient records to support such a finding is not always properly referenced. Moreover, the process for verifying a condition is often time consuming and labor intensive. This results in a few issues, including: MediCare compensation difficulties, missing of important health conditions and/or misdiagnosis, and lastly the clouding of medical analytics with incomplete or incorrect data.
“The first issue, compensation by MediCare, results in providers being underpaid for work performed. This may cause many providers to shy away from MediCare patients, increases cost on other patients, and generally leads to inefficiencies in the administration of government backed medical coverage. Additionally, miss-coding of MediCare claim opens providers to potential audit risk.
“The second issue, improper or incomplete diagnosis, can be extremely detrimental to the patient. Often early treatment of a condition results in a far better prognosis for the patient. In the extreme, delays of treatment may reduce the patient’s life expectancy. As such, there is a very compelling reason to ensure the medical information of a patient is properly documented, with a high degree of accuracy.
“In addition to these direct health impacts to the patient, improper or incomplete diagnosis of the patient can lead to unnecessary tests or follow-ups, which can be financially taxing as well as a drain on the resources of the medical community. Thus there are also tangible financial implications to proper diagnosis with supporting evidence.
“Lastly, incorrect or missing data may result in the skewing of analytics performed using the medical records. The medical community is entering into an age of big data analysis. These analyses of large data sets of aggregated medical records generated best practices and means for refining a medical practice. It also enables early detection of health trends and patient behavior. Using these results, medical professionals have the opportunity to greatly increase the efficiency of the administration of medical services. This translates directly into improved patient care at reduced costs. However, such analysis relies upon datasets that are accurate. When the input data is flawed, or incomplete, the analysis suffers.
“It is therefore apparent that an urgent need exists for improved means for recordation and analysis of medical records. In particular, the clinical state of patients may be determined using a computerized system, which then enables a host of subsequent activities, including: 1) enhanced personalized medicine, 2) coding audit risk management, 3) more complete and accurate record keeping for providers, and 4) MediCare reimbursement optimization via the identification of coding opportunities.”
As a supplement to the background information on this patent application, NewsRx correspondents also obtained the inventors’ summary information for this patent application: “To achieve the foregoing and in accordance with the present invention, systems and methods for managing audit risks are provided. In some embodiments, the true state of the patient is utilized in conjunction with documents and MediCare reimbursement submissions to determine audit risks, and to propose actions to reduce audit risks.
“Initially a number of medical records for a patient are received. These records are subjected to predictive modeling for various conditions (known as patient ‘true state’). The true state is then cross referenced by the eligible Medicare documentation and any findings that are being submitted to MediCare for reimbursement. The result of this cross referencing is the ability to classify each finding and/or true state into one of three categories.
“In some embodiments these categories may be classified as a ‘green zone’, ‘yellow zone’, and ‘red zone’ respectively. The green zone is where the finding, documentation and true state are in good alignment. These cases have very little risk if audited and represent a valid claim for reimbursement.
“In contrast, a red zone is where the finding and the true state are entirely at odds. Typically this is due to a direct error, or the omission of some evidence from the records. These are situations that would fail an audit and require corrective action.
“Lastly, the yellow zone is where the findings and the true state are in agreement, but where there is still audit risk that may be resolved through one or more ‘opportunities’. Often these opportunities revolve around bolstering the documentation for the reimbursement (due to strict Medicare documentation requirements). However, opportunities may also include getting additional evidence to improve the confidence of a true state inference, or even including additional documentation for a finding that exists in the true state, but hasn’t been previously identified.
“In some embodiments it may also be beneficial to validate the true state. The validation process updates the predictive model and updates the confidence level for the inferred true state. Optimized routing on the evidence used for validation may be employed. This routing ensures that evidence that has the greatest impact on the true state inference is presented first.
“Note that the various features of the present invention described above may be practiced alone or in combination. These and other features of the present invention will be described in more detail below in the detailed description of the invention and in conjunction with the following figures.”
The claims supplied by the inventors are:
“1. In a health information management system, a method for managing audit risk, the method comprising: receiving a plurality of medical records for a patient; inferring a true state for the patient using a processor, wherein the true state is inferred from at least one of the plurality of medical records using a predictive model; cross-referencing the inferred true state with at least one coder finding for the patient and MediCare eligible documentation; and classifying each coder finding into one of at least three confidence groups.
“2. The method of claim 1 further comprising generating a confidence level for the inferred true state.
“3. The method of claim 2 wherein the at least three confidence groups include a green zone, a yellow zone and a red zone.
“4. The method of claim 3 wherein the green zone is populated with findings that are aligned with the documentation and the patient true state.
“5. The method of claim 3 wherein the red zone is populated with findings that are misaligned with the patient true state.
“6. The method of claim 3 wherein the yellow zone is populated with findings that have an opportunity.
“7. The method of claim 6 wherein the opportunity is at least one of where additional MediCare documentation is needed to reduce audit risk, a finding does not exist for the patient true state, and the true state has an intermediate confidence level.
“8. The method of claim 2 further comprising validating the true state.
“9. The method of claim 8 wherein the validation updates the predictive model and updates the confidence level for the inferred true state.
“10. The method of claim 8 further comprising optimizing routing of the evidence for validation based upon greatest impact the evidence has on the true state inference.
“11. A health information management system for managing audit risk comprising: an interface configured to receive a plurality of medical records for a patient; and a first pass analyzer including a processor configured to: infer a true state for the patient, wherein the true state is inferred from at least one of the plurality of medical records using a predictive model; cross-referencing the inferred true state with at least one coder finding for the patient and MediCare eligible documentation; and classifying each coder finding into one of at least three confidence groups.
“12. The system of claim 11 wherein the first pass analyzer is further configured to generate a confidence level for the inferred true state.
“13. The system of claim 12 wherein the at least three confidence groups include a green zone, a yellow zone and a red zone.
“14. The system of claim 13 wherein the green zone is populated with findings that are aligned with the documentation and the patient true state.
“15. The system of claim 13 wherein the red zone is populated with findings that are misaligned with the patient true state.
“16. The system of claim 13 wherein the yellow zone is populated with findings that have an opportunity.
“17. The system of claim 16 wherein the opportunity is at least one of where additional MediCare documentation is needed to reduce audit risk, a finding does not exist for the patient true state, and the true state has an intermediate confidence level.
“18. The system of claim 12 further comprising a validation system configured to validate the true state.
“19. The system of claim 18 wherein the validation system updates the predictive model and updates the confidence level for the inferred true state.
“20. The system of claim 18 further comprising a routing optimizer configured to optimizing routing of the evidence for validation based upon greatest impact the evidence has on the true state inference.”
For additional information on this patent application, see: Schneider, John O.; Sethumadhavan, Vishnuvyas; Schulte,
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