Abstract: A computerized system and method for tracking applications and other information for “dual eligible” members of a health insurance plan. The users of computerized system and method are associates of a health benefits provider that offers Medicare Advantage insurance plans to individuals who also may qualify for additional health benefits under another program such as Medicaid. The associates may use the computerized system and method to track activities and interactions with members to qualify them for and to assist them in enrolling in state Medicaid programs. The computerized system and method support tracking of interactions using voice activated technology (VAT) as well as direct mail efforts. The computerized system and method further support recording a member's contact preferences to facilitate additional communications with the member that may be required to complete the eligibility evaluation and for members that are eligible, the enrollment process.

Abstract: A computerized system comprising a social robot for interacting with a patient in order to improve the patient's adherence to a health or medical regime. A patient is instructed to perform a health activity (e.g., take medication, step on scale, measure glucose, play a game) at certain intervals in order to reach a specified goal or expected result. The results of the health activity are recorded in a wireless health device and transmitted to a computer. The computer interprets the result of health activity and communicates an action to the robot. If the patient performs the activity within a specified interval and results are consistent with the specified goal or expected result, the robot communicates relief or pleasure. If the patient does not perform the activity within a specified interval, or if the results are not consistent with the specified goal or expected result, the robot communicates anxiety, disappointment or exhibits symptoms of an effect such as hunger or illness.

Abstract: A computerized system and method for presenting payer-based health record (PBHR) data to a health care provider is disclosed. In an example embodiment, the member summary data is organized on one or more summary pages that contain recent, concise, and relevant information regarding a member of an insurance plan for use by a health provider as a quick reference when care is delivered. In the computerized system and method, a member summary data aggregation process is executed to extract from a member's health profile and claim data relevant information for a member summary. The information contained in a member summary is derived in relation to specific categories. The member summary provides an integrated report of clinically-relevant member-specific medical data for use by a health care provider when care is delivered to the member.

Abstract: A computerized system and method that allows healthcare providers to update the medical codes in health benefits provider member records. Healthcare providers access and update “suspect conditions” for member records in the database. The health benefits provider receives claims for services provided to its members as well as associated, supporting medical records and documentation for the claims. When processing claims, the health benefits provider enters and tracks the claim and related medical data in a database and identifies one or more “suspect conditions” by coding the member records with standardized medical codes such as HCC codes. The healthcare provider researches “suspect conditions” by reviewing supporting documentation and data and updates the records by affirming or denying conditions.

Abstract: A system and method, using one or more dimensions, that assesses the veracity of a diagnosis presently in a health care record is disclosed. The system assesses the veracity of a diagnosis based on a set of dimension values and a set of weightings. The system also provides a user interface to health care providers/caregivers to review the assessment made by the system and may include a feedback mechanism so that the system may adjust the weighting of the dimensions and improve the assessment of the diagnosis made by the system.

Abstract: A computerized system and method for managing requests for medical records and the fulfillment of requests. Multiple users can submit requests for records and view requests already made by other users, and any records received in response to requests. Requests can be searched based on different criteria and reports can be generated regarding requests. Pending requests may be edited to the extent they do not meet the needs of users. Requests may be consolidated and batched together before being sent to a provider. Providers can receive notifications regarding requests that are outstanding. A provider can review requests made, upload records responsive to requests, and delete requests.

Abstract: A computerized system and method to assist young children in tracking and learning about their eating and exercise habits is disclosed. The computerized system and method integrates a pedometer device, a “kid-friendly” website, and a secured server that provides data collection points, a personal health information (PHI) secured data repository, and a reporting/analysis component for food and activity metrics. Health and wellness related data enter by participants via the website includes individual details of food choices, activities, and attitudes towards health and wellness. The computerized system and method may be used as a measurement tool to monitor student health and encourage students to be more aware of their daily choices regarding food and exercise.

Abstract: A computerized system and method for enhancing benefits for members of a health benefits plan. The system and method target behavioral change by integrating personal engagement participation and rewarding individuals that commit to healthy lifestyle choices. The computerized system and method comprises an enrollment process that serves a starting point for determining a consumer's wellness, identifying tools and resources to increase the consumer's wellness, and applying incentives to encourage participation in wellness activities. Consumer enrollment data is stored in a shared repository that also tracks the consumer's participation in wellness activities and to determine eligibility for enhanced plan benefits. Enhanced plan benefits may include increased and/or expanded coverage for primary care and specialty care office visits, and/or reduced co-pays for office visits and emergency room or urgent care visits.

Abstract: A computerized health behavior reward system and method is disclosed. Engagement of rewards program members is based on rewards for participation in a variety of health activities. Health activities are recommended to members based on demographic and health profile information and include general health activities such as participation in fitness programs as well as disease management and clinical programs, educational campaigns, online, interactive, and social networking activities, and community based activities. Each activity may relate to a particular participation event so that members are rewarded for enrolling in a program as well as for ongoing participation. Members earn points for each health activity in which they participate. The points are accumulated in a rewards account accessible from a web site portal and can be redeemed.

Abstract: A computerized system and method for medical record coding is disclosed. The computerized system and method facilitates pre-screening of medical records and analyzes medical record data to identify potential coding errors. When potential coding errors are identified in a record, the suspect record is forwarded to a certified medical coder to confirm the presence or absence of the error. In an example embodiment, synonyms likely to be found in medical records are associated with standardized medical terms and codes and stored in a database. The computerized system and method searches electronic records using the synonyms. If a synonym is present in a record, the system identifies an appropriate code for the associated medical condition confirms that the appropriate medical code is associated with the record. If the code is not found, appropriate action is taken to correct the coding error. Multiple levels of review may be applied to each record.

Abstract: An online application for approving prior authorization requests for prescription drugs. The application is used by pharmacy benefits providers, physicians, and pharmacies to request prior authorizations for drugs and to receive approvals automatically if a requested drug meets authorization criteria. The online application is accessible through a group pharmacy benefits provider portal on a web site. Requests are processed through a pharmacy benefits manager computer that determines whether prior authorization is required and through a pharmacy benefits provider computer when the pharmacy benefits manager computer determines that prior authorization is required. Requests that meet certain authorization criteria are approved automatically. Requests that cannot be approved automatically are submitted for review by a clinical pharmacy review division that access requests through a drug request transaction computer.

Abstract: The present invention is a drug interaction alert system for alerting someone associated with a patient (including in one embodiment the patient himself) that a serious potential for drug interaction in heath care has occurred for the patient based on the occurrence of a triggering event. Health insurance claims data is used in the computerized process to score the degree of seriousness of the drug interactions in care.

Abstract: A computerized system and method for analyzing medical network adequacy. The computerized system and method uses agency guidelines and location information to generate a report as to whether a network of health care service providers satisfies adequacy requirements or access parameters and further identifies why access parameters were not met according to specialty within a county. It further identifies potential health care service providers for addition to the network to improve the compliance of the network. The analysis extends beyond pass-fail compliance with access parameters as determined by a healthcare agency and quantifies the impact of the addition of a non-participating health care services provider to the network. Non-participating health care service providers may be identified in a list and further, rank ordered within the list so that the providers likely to have the greatest impact on the adequacy measure are listed first.

Abstract: An automated prescription dispensing system and method for facilitating dispensing of medications from an automated prescription dispenser designed for in-home use. The dispenser may connect to a remote patient monitoring center for monitoring of the patient's dispenser use and adherence to a medication regime. The dispenser may further connect to a remote medication operations center for monitoring replenishment of the patient's medications and to a remote medical center for monitoring the patient's reaction to medications and clinical signs. A connection to a data analytics center and analytical engine facilitates communications among and between the users and/or caregivers at the remote centers. The dispenser may be loaded with a standardized cartridge that is replenished according to the patient's needs. The dispenser is further equipped with a camera that allows a caregiver at the remote patient monitoring center to view the patient while the patient uses the dispenser.

Abstract: A computerized system and method for automatically estimating the likelihood of having a fall leading to a fracture/dislocation within a specified period is described, and comprises a predictive model for guiding patients to the right course of treatment and encouraging discussions with their doctors for better outcomes. The system and method extracts member's health information from health administrative claims data, including clinical and pharmacy data, and estimates the probability of a fall for that member. Patients with high risk scores are selected for various clinical programs and interventions to manage their health conditions and reduce their likelihood of falling.

Abstract: A financial intermediary for electronic health claims processing is disclosed. The financial intermediary provides consolidated billing of healthcare provider charges for consumers. Consumers receive from the financial intermediary one itemized statement that provides a clear and aggregated view of past medical events and charges from one or more healthcare providers. The statement clearly identifies the consumer's financial responsibility to the healthcare providers and a total amount owed to the providers. The consumer sends a single payment to the financial intermediary and the financial intermediary pays the healthcare providers. In one embodiment, medical events may be organized on the statement according to episodes of care. An episode of care identifier is assigned at the time of provider billing so that charges on a consolidated statement may be organized according to the identifiers. When the statement is generated, the charges are grouped according to identifiers for episodes of care.

Abstract: A computerized back surgery predictive model identifies a risk population for back surgery and assigns a severity level to members of the risk population. High risk members are informed of preference-sensitive surgeries and alternative treatment options. The model focuses on members of the population with back condition related claims and is trained using data for members with primary diagnoses associated with various types of visits, procedures, and treatments for back pain. In an example embodiment, the model is applied to member populations to predict a first back surgery (e.g., spinal fusion, kyphosplasty, vertebroplasty, or decompression surgery) within one year after identified triggers. Predictors are historical risk factors from a broad set of data sources. Members are scored monthly to allow for continuous monitoring of the changing risk of back surgery and to allow timely intervention. The model may be tailored for different populations such as commercial and Medicare populations.

Abstract: A computerized system and method comprises a predictive model for estimating the probability of a patient hospital readmission. The computerized system and method is useful for identifying patients at risk of hospital readmission and further identifying an intervention to mitigate the risk and reduce the likelihood that the patient returns to the hospital. The computerized system method collects and analyzes historical health data from administrative claims data and current health data collected in real-time from medical records at the point of treatment. Signals indicating readmission are extracted from the health data that is collected. The signals are evaluated by the model software application to estimate a probability that a patient will be readmitted to the hospital. Patients with a high readmissions probability score are selected for clinical programs and interventions that help them manage their health conditions and problems and reduce the likelihood that they return to the hospital.

Abstract: An automated system and method for calculating healthcare provider claims metrics and generating reports comprising claims metrics. The automated system and method facilitates provider claims analysis for providers that belong to a healthcare system or network. A computer user enters identifying information for a healthcare provider (such as a tax identification number). The healthcare provider identifying information may be used to generate a report for the individual provider and a system report for the system or network to which the provider belongs. Each report comprises a plurality of metrics related to claims processed for the provider by a healthcare benefits company. The report provides numerous metrics and details regarding the claims processed by the healthcare benefits company. By reviewing the data and additional processing tips, the healthcare provider may identify ways to increase the number of successfully processed claims in a particular time period and to improve its business operations.

Abstract: A computerized clinical action system and method supports a comprehensive view of member health status and identification of candidates for numerous clinical actions such as health alerts and clinical interventions. The computerized system and method facilitate clinical action integration and coordination by providing the infrastructure to share key member information among clinical actions. The computerized system and method comprises a clinical guidance exchange (CGX) that receives and accesses member data from a plurality of sources to facilitate creation of integrated member profiles. The CGX further receives and accesses clinical data from a clinical data hub that integrates clinical data from numerous sources. A rules guidance exchange (RGX) facilitates the identification of candidates for clinical actions through the application of clinical and business rules.