Abstract: The present invention provides a system and method for calculating claim reimbursement recommendations. A medical claim is received and grouped to an rDRG or a median cost value. All similar hospital cases based on the same rDRG are identified. Costs of all comparison cases are then adjusted based on hospital's wage index. Using a pre-selected methodology, the initial target reimbursement amount is calculated. Any applicable override rules and/or inflation factors are then applied to arrive at the reimbursement amount. All relevant information on reimbursement amount and how the amount was calculated is presented to the user.

Abstract: A problem solving expert system is provided which is particularly useful in managing the health care of individual patients. A description of a problem (e.g., medical condition) and a proposed solution therefor (e.g., medical procedure) is entered via a user interface. A topical library is searched to identify information relevant to the problem and proposed solution. Access to the identified information is available in either a full text or synopsis format, to assist a user in assessing the appropriateness of the proposed solution. An inference engine provides a recommendation to the user as to the appropriateness of the proposed solution based on information entered via the user interface and rules associated with the inference engine. A user can interact with the inference engine in either a structured or guided mode.