Abstract: In embodiments, an implementation of a service oriented architecture is provided including an application service bus capable of approximating point-to-point performance by reducing the format transformation of application messages by way of relaying them in a native format when the message format of a consumer application and/or service provider application is supported by the service bus. Preferably, the service bus is capable of supporting multiple message formats and transport protocols and comprises a plurality of components including a Service Initiator module, a Service Terminus module, a Service Locator module, and a Transport module. The service bus provides logical isolation between a consumer application and a provider application by exposing a set of interfaces for relaying service request and service response messages between the applications.

Abstract: An online health care consumer portal for accessing one or more health-related services by a health care consumer. The consumer portal includes an authentication module for identifying the health care consumer upon receiving an online identification token, and a database for maintaining health care information comprising a plurality of health records. The consumer portal also includes a rules engine module for applying a set of rules to the one or more health records corresponding to the consumer to determine an impairment profile of the health care consumer based on the health records corresponding to the health care consumer and an online user interface for providing access to the health-related services. The online user interface is configurable from a default configuration to a second configuration upon identification by the authentication module, the second configuration adapted to facilitate use of the online user interface according to the impairment profile.

Abstract: A business rules externalization system is provided for centrally storing, compiling, and distributing computer readable business rules employed by a plurality of multi-tiered applications executing the rules in native application code. The system includes a rule database for centrally storing the rules in a standardized format, including multiple versions of a given rule or set of rules. The rule externalization system employs a rule object module to declare and store the rules in a standardized format. When an application encounters a trigger point, it interfaces with a rule object module to request the desired rules. The rule object module queries the rule database for the appropriate version of the requested rules and passes the standardized rules to a compiler module. The rule compiler module translates each rule into application-specific computer executable code or format and returns native code-based rules to the rule object module for transmission to the calling application.

Abstract: Ways are provided for a health care organization (HCO) to facilitate payments from a tax-advantaged medical savings account, such as an HSA account, in conjunction with claim processing, by way of automatically debiting an HSA account and providing an integrated claim payment adjustment functionality to eliminate underpayments and/or overpayments for the HSA and health plan balances. A claim processing module reprocesses the claim to adjust the respective balances in one or more of the following ways: (a) HCO crediting the HSA account to eliminate the overpayment from the HSA, (b) HCO issuing a collection request to the health care provider to adjust for overpayment of the HCO balance, (c) HCO issuing a second payment to the health care provider to adjust for the underpayment of the HCO balance, and (d) HCO rebalancing the member and HCO-responsible portions of the claim.

Abstract: To empower a member to make informed health care decisions, a health care organization (HCO) graphically presents the member with a manageable closed universe of health care information via an online interactive visual interface. The online interactive interface comprises a custom category node display of member health care data based on analyzing the member profile in light of the overall health care data taxonomy built by the HCO. Upon identifying the subset of relevant health care data categories, HCO initiates the display of the identified categories by way of a dynamically linked category node interface. To enhance the member's understanding of the relationships between the category nodes, the HCO preferably employs a ring node topology by displaying the online interface as a closed network or map, such as by locating each category node along one or more closed, loop-shaped wireframes, which connect the interrelated categories.

Abstract: A method and system for determining custom population Return on Investment (ROI) forecasted savings estimates for use in evaluating the desirability of active health care management programs and the depth of penetration of such programs. The method and system further include a graphical user interface and returns a statistical confidence of the predicted savings or loss.

Abstract: A system and method are described whereby a health care organization (HCO) cooperates with a financial organization by promoting enrollment and use of a financial product or service that includes terms having incentives related to health care expenditures. In one embodiment, the financial product or service is a credit card program including incentives related to health care expenses. The HCO identifies and selects a group of consumers suitable to receive promotional information related to the credit card program. Preferably, the credit card program is associated with the HCO via a co-branding arrangement. The HCO obtains revenue from the financial organization based on consumer's use of the credit card and, optionally, based on new enrollments. Although a consumer can use the credit card to pay for any product or service, the incentives are applied when the card is used in connection with products or services related to health care.

Abstract: A system and method for administering reductions in future behavioral health care costs through interventions in an insurance plan participant's behavioral health regimen, is disclosed. Information is processed and provided to case managers and/or health care providers in a manner than significantly improves the ability of such individuals to selectively identify plan participants that are most likely to benefit from the intervention. A database is built from a larger set of insurance data, and this data is then further processed to generate, based at least in part on clinical data derived from medical and pharmacy claims, a predictive model that is used to predict the likelihood of future utilization of behavioral health services by a plan participant. The prediction results indicate the relative desirability of intervention in the participant's behavioral health regimen and are used to guide the case, disease, and behavioral health services utilization management for all plan participants.

Abstract: A health account retirement plan (“HARP”) is described that can be used by a retiree for health care related expenses. Under the HARP, an employer pays an annual premium to an insurance company such as a health insurance company. In exchange, the insurer funds and administers health accounts for eligible employees at retirement. Employees become eligible for these benefits according to a pre-determined eligibility schedule comparable to a vesting schedule for pension benefit. Once eligible, if an employee retires, he can use the account for health care related expenses including both premiums and health claims.

Abstract: A system and method are described whereby a healthcare consumer purchases a suspendable plan while having group coverage and is able to suspend the benefits until group coverage becomes unavailable. When group coverage is not desired or is not available, the consumer can activate the benefits under the suspendable plan. Similarly, a healthcare consumer can buy a suspendable plan while not covered by a group plan and activate the benefits under the plan when not employed. The health plan organization, in turn, guarantees renewal of one or more benefits suspended under the plan throughout the life of the policy at the underwriting status determined when the consumer initially applied for suspendable coverage and, most likely, was in better health. When the consumer chooses to suspend one or more benefits under the plan, the healthcare plan organization reduces the plan premium to a residual premium reflecting the risk associated with providing a renewal guarantee.

Abstract: Systems and methods are described for providing consumers with access to the discounted rates for health care procedures provided by primary care physicians, specialist physicians and facilities. Fee information for contracted providers is stored in a database and is accessible to consumers via an online interface. Consumers select query criteria for providers and are presented with actual cost information pertaining to procedures prospectively rendered by providers. Additional information, such as quality or efficiency of providers, can also be presented. Information on multiple providers can be obtained and presented in a comparative arrangement. The presented information can be limited to providers within a geographic region, within a cost range, within a quality range, or other criteria.

Abstract: Techniques are disclosed for identifying opportunities for saving costs and increasing quality of health care. Claim information is organized according to an associated medical condition. A team focused on one major practice category uses historical claim data to identify particularly costly conditions within the major practice category. Additional research is performed with respect to that condition by constructing detailed data requests and reviewing recent literature, publications and news from real and virtual libraries. Using the research and additional data, opportunities are formulated and given to functional work teams to implement in one or more of a variety of ways.

Abstract: Techniques are disclosed for allowing a heath care provider to receive payment from a customer's pre-funded account in exchange for health services provided to a customer, through the use of a healthcare card. The card is issued to the customer by a health plan organization and is linked to a pre-funded account for that customer. The health care provider is under contract with the organization to offer a pre-determined fee structure for covered services. Customers can obtain contracted rates for services via the card, regardless of any limitations that might apply under a health insurance policy or other program. Online, real-time methods are disclosed for the substantiation of payment claims to ensure they are within governmental guidelines for FSA/HRA/HSA coverage. Additional aspects are disclosed whereby health care providers can choose to be paid directly from a health plan organization via an electronic funds transfer into the provider's bank account.

Abstract: A system and method for the efficient administration of health care plans, particularly as to the reduction and/or elimination of avoidable medical costs for select individuals who participate in the plan, is disclosed. Existing health care data is processed to determine an indication as to the relative desirability of an intervention in a plan participant's health care regimen. The data is also processed to determine the status of one or more flags, each of which potentially indicates the relative desirability of an intervention in a plan participant's health care regimen. A predictive model is used to determine the status of a flag relating to the likelihood of an insurance plan participant making a disability claim within a certain period of time.