Abstract: The invention provides a computer implemented method for constructing a patient-specific evidence-informed case rate (ECR) for an episode of medical care spanning a defined period of time for a particular payer-provider-patient triad to create a patient-specific, severity adjusted prospective budget for the patient. ECR Analytics is a tool that constructs episodes of care using administrative claims data, both medical and pharmacy. It calculates the cost of care of patient-specific episodes by assigning relevant services to each episode and further distinguishing those services as typical or routine versus those associated with a complication. The episodes calculated within ECR Analytics can be attributed to specific providers, risk adjusted for performance measurement, and can also be used to construct prospective budgets for payment purposes, such as episode of care payment or reference pricing.

Abstract: The Episode Builder according to exemplary embodiments of the present invention is a web-based computer application and its associated architecture that allows health care professionals to define and describe episodes of care. The Episode Builder provides a unique tool for these purposes. Using industry-standard code sets, the Episode Builder describes and defines an episode of care so that the health care professional can create and modify episodes for a variety of purposes. The three main components of the Episode Builder are a configurable and extensive code set management system, a suite of display panels that define the episodes themselves based upon the code sets, and a means to export the episode definition tables thus created to be used as inputs into an analytic program or a claims adjudication engine.

Abstract: A method for generating healthcare provider quality rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, assessing the claim records in each claim group using guidelines for the particular disease or condition, and generating a compliance score for the claim group, wherein the compliance score indicates the extent to which the claim records in the claim group match the guidelines, and generating normalized provider quality rating data. A method for generating healthcare provider cost rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, calculating the total cost of each claim group, aggregating the total cost for each claim group, and comparing the total aggregate cost of each claim group assigned to each provider to an expected cost value.

Abstract: A method for generating healthcare provider quality rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, assessing the claim records in each claim group using guidelines for the particular disease or condition, and generating a compliance score for the claim group, wherein the compliance score indicates the extent to which the claim records in the claim group match the guidelines, and generating normalized provider quality rating data. A method for generating healthcare provider cost rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, calculating the total cost of each claim group, aggregating the total cost for each claim group, and comparing the total aggregate cost of each claim group assigned to each provider to an expected cost value.

Abstract: A method for generating healthcare provider quality rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, assessing the claim records in each claim group using guidelines for the particular disease or condition, and generating a compliance score for the claim group, wherein the compliance score indicates the extent to which the claim records in the claim group match the guidelines, and generating normalized provider quality rating data. A method for generating healthcare provider cost rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, calculating the total cost of each claim group, aggregating the total cost for each claim group, and comparing the total aggregate cost of each claim group assigned to each provider to an expected cost value.

Abstract: A computer-implemented method for generating healthcare provider quality rating data from healthcare claim records representing services provided by a plurality of healthcare providers (such as physicians or hospitals) to one or more patients includes grouping the claim records into one or more claim groups, each representing services provided to a patient by one or more providers; assigning each claim group to a responsible provider; assessing the claim records in each claim group using guidelines for the particular disease or condition and generating a compliance score for the claim group, wherein the compliance score indicates the extent to which the claim records in the claim group match the guidelines; and generating provider quality rating data for each provider using the normalized aggregate compliance score. The provider quality rating data may include one or more performance categories or graphic symbols that indicate the provider's quality of treatment in comparison to an average value.