Researchers Submit Patent Application, “Systems and Methods for Providing Insurer Risk Data”, for Approval (USPTO 20160196611)

Managed Care Weekly Digest

By a News Reporter-Staff News Editor at Managed Care Weekly Digest -- From Washington, D.C., NewsRx journalists report that a patent application by the inventors Steele, John (Chicago, IL); Young, Steven (Chicago, IL), filed on January 6, 2015, was made available online on July 14, 2016 (see also Pareto Intelligence, Llc).

The patent's assignee is Pareto Intelligence, Llc.

News editors obtained the following quote from the background information supplied by the inventors: "Embodiments provided herein generally relate to systems and methods for providing insurer risk data, and particularly to providing information associated with determining risks that an insurer has taken that are to be compensated through a predetermined program.

"Beginning in 2014 under the Affordable Care Act (ACA), the health insurance industry shifted from the traditional underwritten insurance model to one that is community-rated and guaranteed issue. This means that all enrollees must be accepted and pricing may not vary based on health status. Under the ACA model, various government programs were implemented. As an example, a risk adjustment program was implemented that transfers payments and charges between health insurance carriers within a risk pool based on the relative riskiness of a population. This program was intended to dampen the effects of adverse selection in the community-rated, guaranteed issue markets. As an example, because insurers were no longer allowed to deny coverage or charge increased rates for many preexisting conditions, the risk adjustment program reimburses those insurers who accept individuals (or groups) that are deemed to be 'riskier.' The reimbursements are derived from the insurers who do not take the 'riskier' individuals or groups, so that insurers who do not accept riskier clients will not receive a windfall.

"Additionally, another program that was implemented was a reinsurance program. The reinsurance program was a three-year transitional program in which the federal government covers a part of the claims expense for high cost members within the individual market. By the government compensating insurers for high cost/risk members, the down-side risks for insurers and the incentive for overly conservative pricing are both reduced under the ACA.

"While these new programs provide options for insurers to accept riskier members, many of these insurers do not know the cost-benefit for accepting various members. Additionally, current solutions are not able to provide an accounting of costs, income, and/or other financial data that would allow for an efficient operation under the ACA."

As a supplement to the background information on this patent application, NewsRx correspondents also obtained the inventors' summary information for this patent application: "In one embodiment, a method may include receiving insurance data related to an insurer and determining a captured risk score from the insurance data. The captured risk score may be determined by a predetermined calculation and may be related to a risk taken by the insurer for insuring a first patient that qualifies as a high risk patient, based on first criteria, where the insurer is qualified for compensation for insuring the first patient, based on the captured risk score. Some embodiments of the method include determining a gap risk score from the insurance data, where the gap risk score is determined from a proprietary calculation that is different than the predetermined calculation, and where the gap risk score identifies a second criteria that was not identified in the captured risk score and the qualifies the insurer for an additional compensation. In some embodiments, the method includes providing a user interface that includes data related to the captured risk score and the gap risk score.

"In another embodiment, system may include a processor and a memory component that is coupled to the processor. The memory component may store logic that, when executed by the processor, causes the system to receive insurance data related to an insurer, where the insurance data including information related to coverage provided by the insurer and determine a captured risk score from the insurance data. The captured risk score may be determined by a predetermined calculation and may be related to a risk taken by the insurer for insuring a first patient that qualifies as a high risk patient, based on first criteria, where the insurer is to be compensated for insuring the first patient, based on the captured risk score. In some embodiments, the logic causes the system to determine a gap risk score from the insurance data, where the gap risk score may be determined from a proprietary calculation that is different than the predetermined calculation, and where the gap risk score identifying a second criteria that was not identified in the captured risk score and the qualifies the insurer for an additional compensation. In some embodiments, the logic causes the system to provide a user interface that includes data related to the captured risk score and the gap risk score.

"In yet another embodiment, a non-transitory computer-readable medium may include logic that, when executed by a computing device, causes the computing device to receive insurance data related to an insurer, where the insurance data includes information related to coverage provided by the insurer and determine a captured risk score from the insurance data. The captured risk score may be determined by a predetermined calculation and may be related to a risk taken by the insurer for insuring a first patient that qualifies as a high risk patient based on first criteria, where the insurer is to be compensated for insuring the first patient, based on the captured risk score. In some embodiments, the logic causes the computing device to determine a gap risk score from the insurance data, where the gap risk score may be determined from a proprietary calculation that is different than the predetermined calculation, and may identify a second criteria that was not identified in the captured risk score and the qualifies the insurer for an additional compensation. In some embodiments, the logic causes the computing device to provide a user interface that includes data related to the captured risk score and the gap risk score.

"These and additional features provided by the embodiments described herein will be more fully understood in view of the following detailed description, in conjunction with the drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

"The embodiments set forth in the drawings are illustrative and exemplary in nature and not intended to limit the subject matter defined by the claims. The following detailed description of the illustrative embodiments can be understood when read in conjunction with the following drawings, where like structure is indicated with like reference numerals and in which:

"FIG. 1 depicts a computing environment for providing insurer risk data, according to one or more embodiments shown and described herein;

"FIG. 2 depicts a remote computing device for providing insurer risk data, according to one or more embodiments shown and described herein;

"FIG. 3 depicts a user interface that may be provided to a user for providing risk data related to an insurer, according to one or more embodiments shown and described herein;

"FIG. 4 depicts a user interface that provides population risk segmentation data, according to one or more embodiments shown and described herein;

"FIG. 5 depicts a user interface that provides provider performance data, according to one or more embodiments shown and described herein;

"FIG. 6 depicts a user interface that provides risk gap units, according to one or more embodiments shown and described herein;

"FIG. 7 depicts a user interface that provides provider performance indicators, according to one or more embodiments shown and described herein;

"FIG. 8 depicts a user interface that provides member profile information, according to one or more embodiments shown and described herein;

"FIG. 9 depicts a user interface that provides lost risk members, according to one or more embodiments shown and described herein;

"FIG. 10 depicts a user interface that provides one or more providers with a gap risk, according to one or more embodiments shown and described herein;

"FIG. 11 depicts a user interface that provides a manager platform, according to one or more embodiments shown and described herein;

"FIG. 12 depicts a user interface that provides details of an active campaign, according to one or more embodiments shown and described herein;

"FIG. 13 depicts a user interface that provides one or more options for creating a new campaign, according to one or more embodiments shown and described herein;

"FIG. 14 depicts a user interface that provides data related to campaign activity, according to one or more embodiments shown and described herein;

"FIG. 15 depicts a user interface that provides a campaign dashboard, according to one or more embodiments shown and described herein;

"FIG. 16 depicts a user interface that provides risk management results for a predetermined risk, according to one or more embodiments shown and described herein;

"FIG. 17 depicts a user interface that provides demographic distribution of risk, according to one or more embodiments shown and described herein;

"FIG. 18 depicts a user interface that provides an economic value analysis, according to one or more embodiments shown and described herein;

"FIG. 19 depicts a user interface that provides member economics associated with member segmentation, according to one or more embodiments shown and described herein;

"FIG. 20 depicts a user interface that provides member economics associated with a group segmentation, according to one or more embodiments shown and described herein;

"FIG. 21 depicts a user interface that provides an economic value quintile analysis, according to one or more embodiments shown and described herein;

"FIG. 22 depicts a user interface that provides economic value data for hierarchical condition categories, according to one or more embodiments shown and described herein;

"FIG. 23 depicts a user interface that provides provider population health profile data, according to one or more embodiments shown and described herein; and

"FIG. 24 depicts a flowchart for providing insurer risk data, according to one or more embodiments shown and described herein."

For additional information on this patent application, see: Steele, John; Young, Steven. Systems and Methods for Providing Insurer Risk Data. Filed January 6, 2015 and posted July 14, 2016. Patent URL: http://appft.uspto.gov/netacgi/nph-Parser?Sect1=PTO2&Sect2=HITOFF&u=%2Fnetahtml%2FPTO%2Fsearch-adv.html&r=2008&p=41&f=G&l=50&d=PG01&S1=20160707.PD.&OS=PD/20160707&RS=PD/20160707

Keywords for this news article include: Health Insurance, Pareto Intelligence Llc.