US20210158945A1

US20210158945A1 - Identifying referral patterns between healthcare entities based on billed claims

Info

Publication number: US20210158945A1
Application number: US16/945,257
Authority: US
Inventors: Robert Richards; David Muhlestein
Original assignee: Leavitt Partners Insight LLC
Current assignee: Milliman Solutions LLC
Priority date: 2019-11-22
Filing date: 2020-07-31
Publication date: 2021-05-27
Also published as: US11756002B2; US11935008B2; US11481731B2; US11562327B2; US20210158942A1; US20210158452A1; US11488109B2; US11544671B2; US20210158912A1; US20210158913A1; US20210158911A1; US20210158295A1; US20210158944A1; US20210158943A1; US11763262B2

Abstract

Identifying and quantifying referral patterns between healthcare entities based on billed claims. A method includes determining a plurality of billed claims and identifying one or more unique performing healthcare entities included in at least one of the plurality of billed claims. The method includes identifying one or more unique referring identifiers included in at least one of the plurality of billed claims. The method includes, for at least one of the one or more unique performing healthcare entities, calculating a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims.

Description

CROSS-REFERENCE TO RELATED APPLICATION

This application claims the benefit of U.S. Provisional Patent Application No. 62/939,349, filed Nov. 22, 2019, titled “IDENTIFICATION OF EMPLOYMENT RELATIONSHIPS BETWEEN HEALTHCARE PRACTITIONERS AND HEALTHCARE FACILITIES,” which is incorporated herein by reference in its entirety, including but not limited to those portions that specifically appear hereinafter, the incorporation by reference being made with the following exception: In the event that any portion of the above-referenced provisional application is inconsistent with this application, this application supersedes the above-referenced provisional application.

TECHNICAL FIELD

The disclosure relates generally to the analysis of healthcare systems and particularly to identifying referral patterns between healthcare entities based on healthcare data.

BACKGROUND

The healthcare industry is extraordinarily complex. Specifically, in the United States, relationships between healthcare practitioners, clinics, facilities, groups, and systems are complex and interwoven such that it can be challenging to identify relationships between different entities. One practitioner may see patients that are part of different systems, health insurance networks, or groups. Further, the practitioner may be associated with more than one facility or clinic. The interwoven relationships between healthcare entities makes it challenging to determine if a certain practitioner is associated with or employed by a certain facility, clinic, group, or system. Additionally, other relationships between practitioners, facilities, clinics, groups, and systems throughout the healthcare industry are difficult to identify and quantify.
In some instances, it is necessary or beneficial to understand the relationships between healthcare entities. For example, a health insurance provider seeking to create an in-network selection of providers may need to know which practitioners are associated with which facilities, clinics, groups, or systems. Further for example, a manufacturer or seller of medical devices or pharmaceuticals may benefit from understanding the business relationships between practitioners, facilities, clinics, groups, and systems. In some instances, for example, the manufacturer or seller may sell a medical device or pharmaceutical to a single group, and this would in turn lead to distribution of that medical device or pharmaceutical to hundreds of practitioners associated with the group. These relationships between healthcare entities are nearly impossible to identify or quantify.
In light of the foregoing, disclosed herein are systems, methods, and devices for identifying relationships between healthcare entities.

BRIEF DESCRIPTION OF THE DRAWINGS

Non-limiting and non-exhaustive implementations of the present disclosure are described with reference to the following figures, wherein like reference numerals refer to like parts throughout the various views unless otherwise specified. Advantages of the present disclosure will become better understood with regard to the following description and accompanying drawings where:

FIG. 1 is a schematic diagram of a framework outlining affiliations between healthcare entities;

FIG. 2 is a schematic diagram of a system for data communication between a cohesion component and internal and external data sources;

FIG. 3 is a schematic diagram of a system for performing electronic data security measures on data received from an external data source;

FIG. 4 is a schematic diagram illustrating exemplary data points included in a carrier claim and a facility claim;

FIG. 5 is a diagram of a file organization schematic for Provider Enrollment, Chain and Ownership System (PECOS) enrollment data;

FIG. 6 is a schematic diagram of a process flow for identifying and quantifying “referrals to” relationships between healthcare entities;

FIG. 7 is a schematic diagram of a process flow for identifying and quantifying “referrals from” relationships between healthcare entities;

FIG. 8 is a schematic flow chart diagram of a method for assessing referral patterns between healthcare entities; and

FIG. 9 is a schematic diagram illustrating components of an example computing device.

DETAILED DESCRIPTION

Disclosed herein are systems, methods, and devices for identifying and quantifying referral patterns between healthcare entities. Specifically, disclosed herein are means for measuring referral relationships between healthcare practitioners, facilities, clinics, groups, systems, and other entities based on billed claims.
Current understanding of the healthcare industry in the United States is extremely fragmented. In some instances, it is difficult or impossible to identify systems of care including financial, employment, and enrollment relationships between healthcare entities. The healthcare industry uses multiple data sources for storing billing, procedure, and facility records. There is no one data source that is ideal or reliable for identifying the numerous relationships between healthcare entities. Because healthcare data is fragmented, it can be beneficial to match different types of healthcare data. The matched data can be assessed to identify and quantify relationships between different entities.
Embodiments of the disclosure leverage multiple data sources to describe relationships precisely and completely between healthcare entities. Relationships between practitioners and other healthcare entities cannot be viewed as binary. There are multiple types of affiliations between healthcare entities, and each affiliation may be characterized in terms of its strength. An affiliation reported as merely binary (i.e. yes/no, exists/does not exist, and so forth) masks important information.
Embodiments of the disclosure begin at the level of individual practitioner billing and procedure codes and build from there to identify and quantify relationships between other healthcare entities. By tracking the relationships of individual practitioners to higher level entities, the connections between practitioners and multiple other entities can be identified. This is an improved and more streamlined method when compared with viewing all organizations as discrete, mutually exclusive sets of practitioners.
Embodiments of the disclosure interpret affiliation metrics based on an individualized perspective. For example, a physician's affiliation with a hospital has two perspectives: the physician's perspective and the hospital's perspective. The physician may view the hospital as a necessary portion of the practice that enables the physician to perform certain procedures. The hospital may view the physician as one of many, and the physician's procedures performed at the hospital may represent a very small portion of all procedures performed at the hospital. Understanding affiliations from both perspectives is more informative than viewing the affiliations from only one perspective.
Embodiments of the disclosure describe affiliations in terms of real-world activities that link practitioners to other healthcare entities. This can be performed by assessing disparate data sources in terms of real-world actions or relationships. Some actions, such as referrals or billing of carrier claims 402, may come naturally from a single data source. Other actions, such as geographic practice locations and clinic ownership, require synthesis of multiple data sources. The goal is not merely to represent the data sources, but to leverage the data sources to represent the real world. This results in new metrics and relationships that did not exist before. In embodiments of the disclosure, raw data is manipulated to identify real-world relationships that could not previously be identified or quantified.
Embodiments of the disclosure state affiliations between healthcare entities through action. For example, rather than querying practitioners and other healthcare entities about how they believe they are affiliated, it is more accurate to assess actual behaviors that illuminate real-world relationships free from spin, bias, ignorance, misunderstanding, or self-reported outcomes.
Before the structures, systems, and methods for assessing referral relationships between healthcare entities are disclosed and described, it is to be understood that this disclosure is not limited to the particular structures, configurations, process steps, and materials disclosed herein as such structures, configurations, process steps, and materials may vary somewhat. It is also to be understood that the terminology employed herein is used for the purpose of describing particular embodiments only and is not intended to be limiting since the scope of the disclosure will be limited only by the appended claims and equivalents thereof.
In describing and claiming the subject matter of the disclosure, the following terminology will be used in accordance with the definitions set out below.
It must be noted that, as used in this specification and the appended claims, the singular forms “a,” “an,” and “the” include plural referents unless the context clearly dictates otherwise.
As used herein, the terms “comprising,” “including,” “containing,” “characterized by,” and grammatical equivalents thereof are inclusive or open-ended terms that do not exclude additional, unrecited elements or method steps.
As used herein, the phrase “consisting of” and grammatical equivalents thereof exclude any element or step not specified in the claim.
As used herein, the phrase “consisting essentially of” and grammatical equivalents thereof limit the scope of a claim to the specified materials or steps and those that do not materially affect the basic and novel characteristic or characteristics of the claimed disclosure.
Reference will now be made in detail to the exemplary embodiments, examples of which are illustrated in the accompanying drawings. Wherever possible, the same reference numbers are used throughout the drawings to refer to the same or like parts. It is further noted that elements disclosed with respect to embodiments are not restricted to only those embodiments in which they are described. For example, an element described in reference to one embodiment or figure, may be alternatively included in another embodiment or figure regardless of whether or not those elements are shown or described in another embodiment or figure. In other words, elements in the figures may be interchangeable between various embodiments disclosed herein, whether shown or not.
Referring now to the figures, FIG. 1 illustrates a framework 100 that outlines affiliations between healthcare entities. The framework 100 illustrates a hierarchy of healthcare entities, wherein some healthcare entities can “roll up” to other hierarchal healthcare entities. The framework 100 is built from the ground up and begins with the practitioner 102. The practitioner may be affiliated with facilities 110 and/or clinics 106. A facility 110 may be affiliated with a system 118. A clinic 106 may be affiliated with a group 114. There may be affiliations between systems 118 and groups 114 and between facilities 110 and clinics 106. The claims billed in association with facilities 110 and systems 118 may be referred to herein as procedure billing 122. The procedure billing 122 claims may be filed as facility claims (see 404 at FIG. 4). The claims billed in associated with clinics 106 and groups 114 may be referred to herein as office billing 124. The office billing 124 claims may be filed as carrier claims (see 402 at FIG. 4).
In an embodiment, the hierarchy of the framework 100 begins with the practitioner 102. The practitioner 102 can roll up to a clinic 106 level, and the clinic 106 and the practitioner 102 may roll up to the group 114 level. Additionally, the practitioner 102 can roll up to a facility 110 level, and the facility 110 and the practitioner 102 may roll up to the system 118 level. As discussed herein a hierarchal healthcare entity may refer to some other entity in the framework 100 that has a connection to another entity. For example, practitioners 102, clinics 106, and groups 114 may be referred to as hierarchal healthcare entities to one another. Additionally, practitioners 102, facilities 110, and system 118 may be referred to as hierarchal healthcare entities to one another.
In an embodiment of the framework 100, a distinction is drawn between systems 118 that may own facilities 110, and groups 114 that may own clinics 106. This distinction is made for illustrative purposes and to increase the accuracy of conclusions drawn from assessing healthcare affiliations. In some instances, this distinction does not exist in the real world, and systems 118 and groups 114 are the same entity. This approach permits individual practitioner behaviors to be leveraged to describe the relationships of higher-level entities with one another.
The practitioner 102 is a healthcare practitioner such as a physician (Doctor of Medicine), physician assistant, nurse practitioner, podiatrist, dentist, chiropractor, psychologist, optometrist, nurse midwife, clinical social worker, and so forth. The practitioner 102 may be a single person licensed to provide healthcare advice or guidance, perform procedures, prescribe medications, and so forth. The practitioner 102 may be a solo practitioner, may be associated with a group of other practitioners 102 in a clinic 106 or other group setting, may be employed by a facility 110 such as a hospital, may be employed as an in-house practitioner, and so forth. In some instances, it can be beneficial to identify and quantify the practitioner's 102 relationships with other entities such as clinic 106, facilities 110, groups 114, and systems 118.
The practitioner 102 may be associated with a practitioner ID 104. In some embodiments, the practitioner ID is an individual NPI (National Provider Identifier). In the United States, an individual National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) administrative standard. An individual NPI is a unique identification number for covered healthcare providers. In the United States, covered healthcare providers, health plans, and healthcare clearinghouses are directed to use NPIs in administrative and financial transactions. It should be appreciated that the practitioner 104 may be associated with any unique identifier and does not need to be associated with a National Provider Identifier. The use of some other unique identifier does not depart from the scope of the disclosure. The practitioner ID 104 is a unique code associated with the practitioner 102. It should be appreciated that the practitioner ID 104 is any unique code associated with the practitioner 102 and can include other codes without departing from the scope of the disclosure.
The clinic 106 is a group of practitioners, a single practitioner, or some other entity that is primarily focused on the care of outpatients. The clinic 106 may be an outpatient clinic, an ambulatory care clinic, a physical therapy clinic, a specialist clinic, an urgent care clinic, an employer-funded in-house healthcare clinic, and so forth. The clinic 106 may be a group of practitioners that practice together at the same physical location or at different physical locations. The clinic 106 may include one or more practitioners 102 that practice telehealth care over the phone, over video communications, or by some other form of communication. The clinic 106 may be privately operated or publicly managed and funded. The clinic 106 may be suited for covering primary healthcare needs or specialized outpatient healthcare needs for populations of communities, in contrast with larger hospitals that offer specialized treatments and admit inpatients for overnight stays. The clinic 106 is not limited to only providing outpatient care.
The clinic 106 may be associated with a clinic ID 108. In some embodiments, the clinic ID 108 is an organization NPI (National Provider Identifier). In the United States, an organization National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) administrative standard. An organization NPI is a unique identification number for covered healthcare clinics. The clinic ID 108 is a unique code associated with the clinic 106. If the clinic 106 has multiple geographic locations, then each of the multiple geographic locations for the clinic 106 may have a unique clinic ID 108. In some instances, two or more locations for the same clinic 106 share a clinic ID 108. It should be appreciated that the clinic 106 may be associated with any unique identifier and does not need to be associated with an organization NPI. The use of some other unique identifier does not depart from the scope of the disclosure.
The facility 110 is a physical or virtual healthcare location where an individual can receive care from a practitioner 102. The facility 110 may include hospitals, ambulatory surgical centers, birth centers, blood banks, dialysis centers, hospice centers, imaging and radiology centers, mental health and addiction treatment centers, nursing homes, orthopedic and other rehabilitation centers, telehealth systems, and so forth. In some implementations, it is not necessary to provide a formal definition for a facility 110 versus a clinic 106, and this distinction can be drawn based on the factual circumstances of various healthcare entities.
In an example embodiment, the facility 110 is linked to a facility ID 112. In some embodiments, the facility ID 112 is a Centers for Medicare and Medicaid Services (CMS) Certification Number, which is referred to as a CCN. In the United States, the CCN is the facility's 110 unique identification code that is linked to the facility's 110 provider agreement for Medicare billing. In some instances, the CCN is referred to as the facility's 110 “provider number.” The facility ID 112 is used for submitting and reviewing the facility's 110 cost reports. It should be appreciated that the facility 110 may be associated with any unique identifier and does not need to be associated with a CCN. The use of some other unique identifier does not depart from the scope of this disclosure.
The group 114 is a healthcare entity that owns one or more clinics 106. The group 114 may alternatively be referred to as a “provider group.” In some instances, there is no real-world distinction between groups 114 and systems 118, and this distinction is made in the systems, methods, and devices disclosed herein for the purpose of improving analytics on various healthcare entities. In some instances, a single healthcare entity may be referred to as a group 114 and as a system 118 for purposes of improving the analytics described herein.
The group 114 may be associated with a group ID 116. In some embodiments, the group ID 116 is a PAC ID (Practice Access Code ID) assigned by PECOS (Provider Enrollment, Chain and Ownership System). The PECOS is a system used in the United States and enables practitioners and other healthcare facilities to register with the Centers for Medicare and Medicare Services. PECOS is the Provider, Enrollment, Chain, and Ownership System. The system 118 may further be associated with the group ID 116. In some cases, a group 114 and a system 118 are the same entity and are associated with the same group ID 116. In some cases, a group 114 and a system 118 are separate entities to the degree that the group 114 is associated with its own group ID 116 and the system 118 is associated with its own system ID 120.
The system 118 is a healthcare entity that owns one or more facilities 110. In some instances, there is no real-world distinction between groups 114 and systems 118, and this distinction is made in the systems, methods, and devices disclosed herein for the purpose of improving analytics on various healthcare entities. In some instances, a single healthcare entity may be referred to as a group 114 and as a system 118 for purposes of improving the analytics described herein.
There are numerous metrics that can be calculated based on the relationships between practitioners 102, clinics 106, facilities 110, groups 114, and systems 118. In some cases, the metrics are determined based on claims billed by any of the entities described in FIG. 1. Some basic affiliation metrics that can be calculated include practitioner billing metrics, clinic billing metrics, practitioner enrollment metrics, clinic enrollment metrics, practitioner-group billing metrics, group billing metrics, practitioner-facility procedure volume metrics, facility procedure volume metrics, practitioner-facility employment metrics, facility-clinic distance metrics, and others. The practitioner billing metric is the proportion of a practitioner's total carrier claims 402 billed to a certain clinic associated with a specific clinic ID 108. The clinic billing metric is the proportion of total carrier claims 402 billed under a clinic performed by a given practitioner. The practitioner enrollment metric is the clinics at which a practitioner is enrolled in the PECOS. The clinic enrollment is the practitioner(s) enrolled in the PECOS under a clinic. The practitioner-group billing is the proportion of the practitioner's carrier claims 402 billed under any of the group's clinics. The group billing is the proportion of all carrier claims 402 billed under any of the group's clinics that were performed by a specific practitioner. The practitioner-facility procedure volume is the proportion of a practitioner's total procedure claims performed at each facility. The facility-procedure volume is the proportion of the procedures performed at the facility performed by each practitioner. The practitioner-facility employment is the level of confidence that the practitioner is employed by a given facility. The facility or clinic distance is the distance between a clinic and a facility in miles or some other distance measurement.
Practitioners 102 bill for services and devices through procedure billing 122 and office billing 124. In most implementations, when a practitioner 102 performs a procedure at a hospital, surgical center, or other facility 110, the practitioner's 102 activity leads to a facility claim 404 that identifies the appropriate facility 110. Further in most implementations, when a practitioner 102 performs an office visit or other service at a clinic 106, the practitioner 102 bills a carrier claim 402 that identifies the appropriate clinic 106. The procedure billing 122 submitted by one or more practitioners 102 can be assessed to identify and quantify relationships between facilities 110 and systems 118. Similarly, the office billing 124 submitted by one or more practitioners 102 can be assessed to identify and quantify relationships between clinics 106 and groups 114.
As discussed herein, procedure billing 122 may be associated with a procedure billing identifier. The procedure billing identifier may comprise one or more of the system identifier 120 or the facility identifier 112. Therefore, the procedure billing identifier includes any applicable identifier associated with procedure billing 122. The procedure billing identifier is a means for identifying one or more of a system 118 or a facility 110. The procedure billing identifier may be included in a procedure billing 122, such as a facility claim 404 or another claim associated with a system 118 and/or facility 110. The procedure billing identifier as discussed herein includes a system identifier 120 and/or a facility identifier 112 as applicable in the pertinent use-case.
As discussed herein, office billing 124 may be associated with an office billing identifier. The office billing identifier may comprise one or more of the group identifier 116 or the clinic identifier 108. Therefore, the office billing identifier includes any applicable identifier associated with office billing 124. The office billing identifier is a means for identifying one or more of a group 114 or a clinic 106. The office billing identifier may be included in an office billing 124 such as a carrier claim 402 or another claim associated with a group 114 and/or a clinic 106. The office billing identifier as discussed herein includes a group identifier 116 and/or a clinic identifier 108 as applicable in the pertinent use-case.
FIG. 2 is a schematic diagram of a system 200 for data communication between a cohesion component 202 and internal and external data sources. The cohesion component 202 identifies and manipulates data from multiple sources to determine cohesion between various healthcare entities. The matched data can then be analyzed to identify and quantify relationships between different healthcare entities. The cohesion component 202 performs these calculations based on real-world claim data and/or enrollment data that can be stored in a combination of internal and external data sources. The cohesion component 202 may communicate with one or more of an internal data source 204 and an external data source 206. The internal data source 204 may be a database, data store, or other memory device that is “internal” to the cohesion component 202 or is managed by the same entity as the cohesion component 202. The external data source 206 may be a database, data store, or other memory device that is “external” to the cohesion component 202 or is managed by some other entity such that the cohesion component 202 must access that data by way of an Application Program Interface (API), by receiving a file, by accessing an external server, and so forth.
In an embodiment, the cohesion component 202 communicates directly with an external data source 206 that is managed or owned by a third-party entity. In an embodiment, the external data source 206 is owned and managed by the Medicare system operated by the United States government, or by some other entity that has been tasked with managing data for the Medicare system. In an embodiment, the external data source 206 is a relational database, and the cohesion component 202 communicates with the relational database by way of an Application Program Interface (API). In an embodiment, the external data source 206 is an encrypted hard drive that has been shared with the cohesion component 202. In an embodiment, the external data source 206 is a virtual data center, and the cohesion component 202 accesses the data on a virtual server after signing in or undergoing some other authentication step.
In an embodiment, the cohesion component 202 communicates with an internal data source 204 that is not managed by some other third-party entity. The internal data source 204 may include a file that has been downloaded or otherwise received from some third-party entity, such as the Medicare system. After the file has been downloaded, the file can be managed and manipulated by the cohesion component 202. The internal data source 204 may include an encrypted hard-drive or downloaded encrypted file that is provided by a third-party, such as the Medicare system.
The cohesion component 202 may receive and translate information from multiple different sources. In an example implementation, the cohesion component 202 receives enrollment information from a central data warehouse that may be operated internally or by a third-party. The cohesion component 202 further receives claims data from a different source, for example via a secure connection to a virtual data store by way of an API, by accessing an encrypted hard drive, or accessing an encrypted file that has been downloaded by way of a network connection.
In an embodiment, the data stored in the internal data source 204 has been “cleaned” or pared down to only include necessary or critical information. This can be beneficial to ensure the totality of the data is a usable size that can be efficiently queried, analyzed, and manipulated. For example, the raw data retrieved from the external data source 206 may include numerous data fields that are not necessary for identifying a certain relationship between healthcare entities. The unnecessary data may be eliminated, and only the necessary data may be stored on the internal data source 204. In an embodiment, the raw data is cleaned and stored in a relational database.
In an embodiment, the cohesion component 202 analyzes information stored in the internal data source 204 and/or the external data source 206 by identifying relationships between individual practitioners 102 and their associated clinics 106 and groups 114. In an example use-case, the cohesion component 202 identifies that Doctor A is performing work for Clinic B. The cohesion component 202 then identifies all the practitioners that associate with Clinic B and assesses the carrier claims billed by those practitioners. The cohesion component 202 aggregates the claim information for all practitioners in Clinic B and combines the information in an effort to answer specific questions, such as whether and to what extent practitioners 102 billing at the clinic 108 are also billing at other clinics 108.
The cohesion component 202, or some other module or component in communication with the cohesion component 202, may create intermediary files or tables within a relational database. The intermediary files or tables may include certain information columns that are pertinent to answer a specific question, such as identifying or quantifying a relationship between two or more healthcare entities. This can be beneficial to ensure that each intermediary file or table is no bigger than it needs to be to include all necessary information for answering the specific question. This decreases the amount of disc storage and/or Random-Access Memory (RAM) needed to analyze the information and calculate the answer to the specific question.
FIG. 3 is a schematic diagram of a system 300 for performing electronic data security measures on data received from the external data source 206. The cohesion component 202 receives claims data (see 302) from an external data source 206. The claims data may include carrier claims, facility claims, and other claims generated or processed by private or public healthcare entities. Claims data includes sensitive information such protected personal information (PPI) and personal identifiable information (PII), and therefore, the claims data must be encrypted or otherwise secured.
In an embodiment, the cohesion component 202 receives claims data by securely communicating with a virtual data center (see 310). The virtual data center may be provided by a private or public healthcare entity. In an embodiment, an account is created for a user associated with the cohesion component 202, and the user can sign into the virtual data center with the account. The user can then access the data stored in the virtual data center 310 by way of the account. The data may be encrypted or non-encrypted based on the security measures of the virtual data center. In an embodiment, the data is non-encrypted when viewed by way of a network connection, and the data is encrypted if downloaded for offline use and manipulation. If the data is downloaded in an encrypted form, then the data must be de-encrypted prior to analysis and manipulation.
In an embodiment, the cohesion component 202 receives claims data by way of an encrypted hard drive. The encrypted hard drive may be provided by the source of the data, such as private or public healthcare entity. In an embodiment, the cohesion component 202 receives claims data by way of an encrypted file that has been downloaded by way of a network connection. The cohesion component 202 undergoes an electronic data security measure 308 by de-encrypting the claims data (see 312).
FIG. 4 is a schematic diagram illustrating exemplary components of carrier claims 402 and facility claims 404. A carrier claim 402 is a non-institutional medical billing claim submitted by or on behalf of a practitioner 102. The carrier claim 402 may be billed for outpatient or inpatient services. The carrier claims 402 used by the data merging component 202 may include carrier claims 402 submitted through the Medicare system implemented in the United States and may additionally include carrier claims for private entities such as private health insurance agencies. If the carrier claims 402 include Medicare claims, then the carrier claim may be submitted on the health insurance claim form CMS-1500 used by the United States Medicare system.
Carrier claims 402 include information about a service provided by a practitioner 102 in an outpatient or inpatient setting. In some instances, only a portion of the information included in the carrier claim 402 is relevant to the analysis of whether a relationship exists between two or more healthcare entities. Carrier claims 402 may include a patient identifier (ID) 406, which may include a numerical or alphanumerical code assigned to the patient, and may further include the patient's name, address, or other contact information. Carrier claims 402 further include a practitioner ID 104 which may specifically include an individual NPI. The carrier claim 402 may include a clinic ID 108, or some other information identifying the name, location, or contact information of the clinic under which the service was performed. The carrier claim 402 includes an indication of the date of service 408 when the service was performed or on what date the service began if the service extended over multiple days. The carrier claim 402 includes an indication of the place of service 410, and this may be a numerical or alphanumerical code identifying a type of facility, and may also include a name, address, or other contact information for the facility. The carrier claim 402 includes one or more billing codes 412 identifying the services or procedures that were performed by the practitioner 102. The billing code 412 may include a Healthcare Common Procedure Coding System (HCPCS) code. The carrier claim 402 may further include an indication of the days or units 414 indicating a duration of time the procedure occurred. The carrier claim 402 may further include a referring identifier 418 that identifies a referring party. A referring party may include a practitioner 102, a clinic 106, a facility 110, a group 114, a system 118, or some other entity. For example, in the case where the referring party is a practitioner 102, the referring identifier 418 will be the practitioner identifier 104 associated with that practitioner 102.
The facility claims 404 may include similar information. If the facility claims 404 include Medicare claims, then the facility claims may be submitted on the health insurance claim form UB-40 used by the United States Medicare system. The facility claims 404 may include, for example, the patient ID 406, practitioner ID 104, facility ID 112, date of service 408, place of service 410, billing code 412, days or units 414, and an indication of the type of visit 416. The facility ID 112 identifies the facility at which the procedure was performed, and may take the form of an NPI, CMS Certification Number or CCN, or some other way of identifying the name, location, and contact information of the facility. The indication of the type of visit 416 may be a numerical code indicating whether the visit was an emergency, an outpatient visit, an inpatient visit, and so forth. The facility claim 404 may further include a referring identifier 418 that identifies a referring party. A referring party may include a practitioner 102, a clinic 106, a facility 110, a group 114, a system 118, or some other entity. For example, in the case where the referring party is a practitioner 102, the referring identifier 418 will be the practitioner identifier 104 associated with that practitioner 102.
Each of a carrier claim 402 and a facility claim 404 may include one or more referring identifiers 418. The referring identifier 418 identifies a referring healthcare entity that referred the patient to the performing healthcare entity that performed the procedure. In some implementations, a claim includes a plurality of unique referring identifiers 418. This may occur when multiple parties refer a patient for a certain procedure. Further in an embodiment, a claim may have a single referring identifier 418 and a plurality of performing healthcare entities. In such an embodiment, the single referring identifier 418 may be seen as referring the patient to each of the plurality of performing healthcare entities. This might occur when, for example, the patient receives surgical treatment from multiple practitioners 102 such as surgeons and anesthesiologists, and the patient additionally receives treatment from the facility 110 where the surgery was performed.
In an example implementation, a patient sees a primary care physician (a practitioner 102), and the primary care physician refers the patient to an orthopedic surgeon (also a practitioner 102) for treatment. The patient may receive treatment at a surgical center or hospital (a facility 110) performed by the orthopedic surgeon. The patient may be billed a carrier claim 402 and/or a facility claim 404 for the treatment. Each of the carrier claim 402 and the facility claim 404 may include an indication that the patient was referred by the primary care physician. This may be denoted by including the practitioner ID 104 for the patient's primary care physician.
Carrier claims 402 may include additional information not illustrated in FIG. 4, For example, carrier claims 402 may include an indication of whether the bill is being submitted through a government-funded plan such as Medicare, Medicaid, Tricare, or CHAMPVA, or a private health insurance plan. The carrier claim 402 may include insurance information, such as the insured's ID number, name, address, birth date, policy name, group number, policy number, whether there is an additional health benefit plan, and so forth. The patient ID 406 information may include the patient's name, address, telephone number, and so forth. The carrier claim 402 may include an indication of whether the patient's condition is related to employment, an automobile accident, or some other accident. The date of service 408 information may include an indication of what date the current illness, injury, pregnancy, or other condition began. The date of service 408 may further include other applicable dates. The carrier claim 402 may include information about what dates the patient was unable to work in his or her current occupation, dates of hospitalization related to the current services, charges made to an outside lab in relation to the current services, and so forth. The carrier claim 402 may include information about a referring provider or other source, such as the referring provider's individual NPI. The billing code 412 may include a diagnosis code or an indication of the nature of illness or injury and may further include a CPT or HCPCS code indicating the procedures, services, or supplies used in connection with the billed claim. For each billing code 412 listed in the carrier claim 402, there is also an indication of the date of service, the place of service, the diagnosis pointer, the charges, the days or units, and the rendering provider's practitioner ID 104 for that service, procedure, or supply. The carrier claim 402 may further include a federal tax ID number for the practitioner 102, a patient account number relating to the practitioner's practice, a total charge and the amount paid. The carrier claim 402 additionally includes information on the facility where the service, procedure, or supply was administered to the patient. The information on the facility may include the name, address, contact information, or a clinic ID 108 or facility ID 112 related to the facility.
Facility claims 404 may include additional information not illustrated in FIG. 4. The facility claims 404 may include all the information listed above with reference to the carrier claims 402. The facility claims 404 may additionally include information on when the patient was admitted to the facility, the condition codes pertaining to why the patient was admitted to the facility, and the dates the patient was in-patient or out-patient at the facility. The facility claim 404 may include numerous practitioner IDs 104 pertaining to each of the numerous practitioners 102 who assisted in the patient's care while the patient was at the facility 110. Each service, procedure, or supply administered to the patient during the patient's stay at the facility 110 may linked to a certain practitioner 102.
FIG. 5 is a schematic diagram of PECOS enrollment 502 information relationships. In the United States, the PECOS is used to track the status of healthcare practitioners, and the relationships those healthcare practitioners have with other entities, such as clinics 106, facilities 110, and groups 114. In the PECOS, a practitioner 102 is assigned a practitioner ID 104 in the form of an individual NPI. Additionally, other entities are assigned identification numbers. A clinic 106 is assigned a clinic ID 108 in the form of an organization NPI. A facility 110 is assigned a facility ID 112 in the form of a CMS Certification Number (CCN). A group 114 is assigned a group ID 116 in the form of a PAC ID.
Within PECOS, a practitioner 102 can assign rights to another entity, such as a clinic 106, facility 110, and/or group 114 by storing a reassignment file that links the practitioner's 102 practitioner ID 104 to the clinic ID 108, the facility ID 112, and/or the group ID 116, as applicable. The practitioner 102 can enroll under another entity, such as the clinic 106, the facility 110, and/or the group 114. The practitioner 102 can submit an indication to PECOS that the practitioner 102 is professionally associated with a clinic 106, facility 110, and/or group 114.
In an example, a practitioner is an emergency medicine physician employed by a hospital. The physician is enrolled in PECOS and supplies an individual NPI, assigned previously by the National Plan and Provider Enumeration System (NPPES). A PECOS Associate Control (PAC) ID is assigned to the practitioner, and an enrollment ID is assigned to each of the practitioner's enrollments. Additionally, the hospital is enrolled in PECOS as a facility and supplies an NPI previously assigned. A PECOS Associate Control (PAC) ID is assigned to the facility, and an enrollment ID is assigned to each of the facility's enrollments. The physician may indicate within PECOS that the physician has assigned rights to the hospital, or that the physician is otherwise associated with the hospital, by linking one or more of his or her enrollment IDs with one or more enrollment IDs of the hospital in a reassignment file.
The PECOS enrollment 502 information is not always accurate. The enrollment information within PECOS is often stale with respect to real-world relationships. For example, a practitioner may transition from being employed by a hospital to operating as a sole proprietor. This change is reflected in PECOS only if the practitioner or some other entity indicates within PECOS that the change has occurred. In such an instance, PECOS is not reliable to indicate the real-world professional relationships for that practitioner. In such an instance, the carrier claims submitted by the practitioner can be analyzed in lieu of the information in PECOS, and the analysis gleaned from the carrier claims can be used to override the information in PECOS to identify the practitioner's real-world relationships.
FIGS. 6 and 7 are schematic diagrams of process flows 600, 700 for identifying and quantifying referral patterns between healthcare entities. The process flow 600 can be used to quantify “referrals from” relationships and the process flow 700 can be used to quantify “referrals to” relationships. In an embodiment, the “referrals from” relationships identify and quantify the referrals a performing healthcare entity is receiving from others. This is the amount of business the performing healthcare entity is receiving from other referring healthcare entities. In an embodiment, “referrals to” relationships begin with the practitioner 102 level and represent referrals that one practitioner sends to other practitioners. This is the amount of business the referring practitioner is sending to other performing practitioners.
All claim types, including carrier claims 402 and facility claims 404, have referring identifiers on the claims. The referring identifier 418 may include one or more of practitioner IDs 104, clinic IDs 108, facility IDs 112, and so forth. The referring identifier 418 is a unique identifier indicating a practitioner 102, clinic 106, facility 110, and so forth. The referring identifiers 418 included in billed claims can be used to establish referral patterns between various practitioners 102, clinics 106, facilities 110, groups 114, and systems 118. These referral patterns may first be calculated from the practitioner 102 level to all other levels, including practitioners 102, clinics 106, facilities 1106, groups 114, and/or systems 118. From there, the relationships can be rolled up to other levels of hierarchal aggregation. For example, a method may include quantifying referrals between clinics 106, facilities 110, groups 114, systems 118, and practitioners.
As discussed herein, a “performing healthcare entity” refers to a healthcare entity that performed or provided a service. The performing healthcare entity may be identified based on a unique identifier associated with the performing healthcare entity, such as a practitioner ID 104, a clinic ID 108, a facility ID 112, and so forth, as applicable. The service performed by the performing healthcare entity may be included on a billed claim sent to the patient or the patient's payer. A performing healthcare entity may include any of a practitioner 102, a clinic 106, a facility 110, a group 114, or a system 118. The performing healthcare entity may “roll up” to other hierarchal healthcare entities. For example, the performing healthcare entity listed on the billed claim may include a practitioner 102, and this practitioner 102 may be rolled up to associated clinics 106, facilities 110, groups 114, or systems 118, as applicable.
As discussed herein, a “referring healthcare entity” refers to a healthcare entity that referred a patient to another performing healthcare entity to receive a service. The referring healthcare entity may be identified based on a unique identifier associated with the referring healthcare entity, such as a practitioner ID 104, a clinic ID 108, a facility ID 112, and so forth, as applicable. If the patient receives the service referred by the referring healthcare entity, then the patient may receive a billed claim by the performing healthcare entity. This billed claim may identify the referring healthcare entity. The referring healthcare entity may be a practitioner 102, a clinic 106, a facility 110, a group 114, or a system 118, as applicable. The referring healthcare entity may “roll up” to other hierarchal healthcare entities. For example, the referring healthcare entity listed on the billed claim may include a practitioner 102, and this practitioner 102 may be rolled up to associated clinics 106, facilities 110, groups 114, or systems 118, as applicable.
The process flow 600 can be used to identify and quantify from which referring healthcare entities a performing healthcare entity is receiving work. The process flow 600 may begin with determining aggregated claims over a time period 602. The aggregated claims may include, for example, all carrier claims billed by a practitioner 102 over a calendar year, or all facility claims billed by a facility 110 over a financial quarter. For example, the claims may include all claims billed by a certain practitioner 102, or all claims billed by a clinic 106, or all claims billed by a group 114 over a time period. Further, the aggregated claims may include all claims processed through a certain healthcare network such as Medicare, Medicaid, or a private healthcare network over a time period. The aggregated claims may include all claims processed by numerous healthcare networks within a certain geographic region over a time period. It should be appreciated that the claims may be aggregated in any suitable manner depending on the application. The claims may include carrier claims 402 and/or facility claims 404. The claims may be associated with a single healthcare entity or with a plurality of healthcare entities.
The process flow 600 may include identifying referring identifiers 418 in the aggregated claims. The referring identifiers 418 identify a referring healthcare entity associated with that claim. For example, the referring identifier 418 may be practitioner ID 104 associated with a practitioner 102 who referred the patient to the performing healthcare entity for the claim. The referring identifiers 418 may include an identifier for one or more of a referring practitioner 604, a referring clinic 606, a referring facility 608, and so forth, as applicable.
The process flow 600 may include calculating a proportion of referrals within the aggregated claims that came from each of the unique referring identifiers 418. This may include calculating a proportion of referrals coming from each practitioner ID 610, a proportion of referrals coming from each clinic ID 612, and/or a proportion of referrals coming from each facility ID 614. The process flow 600 may include rolling up the proportions to hierarchal healthcare entities such as clinics, facilities, groups, and/or systems, as applicable.
“Referrals from” are the referrals a practitioner 102 or other performing healthcare entity receives from other referring healthcare entities. This shows where the performing healthcare entity's business from referrals is coming from. This can help identify, for example, groups of practitioners 102 that work almost exclusively for a facility 110 or system 118 without being employed by or doing procedures at the facility 110 or system 118.
The “referrals from” metrics include referrals from proportions and referrals from concentration. The referrals from proportions metric includes, for all performing healthcare entities receiving referrals, the proportion of their referrals coming from other specific referring healthcare entities. This metric represents multiple measures, one for each pairing of referring/performing healthcare entities. The referrals from concentration metric includes, for all referring healthcare entities and performing healthcare entities receiving referrals, a score summarizing the concentration of their specific referrals to proportions (specifically, sum of squared proportions). The referrals from concentration metric may be performed for each performing healthcare entity that receives referrals.
In an embodiment, a process for calculating “referrals from” metrics includes the following. First, claims data over a time period is aggregated. The claims data may include carrier claims 402 and/or facility claims 404. The claims data is analyzed to identify all referring healthcare entities based on the referring identifiers 418 included in the claims data. claims data is further analyzed to identify all performing healthcare entities based on the identifiers included in the claims data as a billing entity. It should be noted that a single claim may include a plurality of performing healthcare entities. The process includes, for each performing healthcare entity, calculating a proportion of referrals coming from each unique referring healthcare entity. This may be performed for facilities 110 and practitioners 102. These proportions represent the proportion of the performing healthcare entity's business coming from each referring healthcare entity. These proportions may be rolled up to clinics 106, facilities 110, groups 114, and systems 118 to represent the proportion of business the clinics 106, facilities 110, groups 114, and systems 118 are receiving from each referring healthcare entity.
In an embodiment, further derivatives of referral patterns may be calculated. In an embodiment, a method includes identifying and quantifying the self-referrals for a performing healthcare entity. In an example implementation, a practitioner 102 evaluates a patient and refers the patient to undergo surgery. The same practitioner 102 who evaluated the patient may also perform the surgery.
In an embodiment, a method includes calculating a proportion of a performing healthcare entity's business that originates from referrals. This is the percent of all claims the entity files which include some sort of referring identifier 118, as opposed to having no such referring identifier (business not generated by specific referral).
In an embodiment, a method includes calculating the capture rate of a system's 118 and/or a group's 114 capture or referrals. These metrics may be calculated by identifying the referrals made by practitioners within a clinic 106, group 114, facility 110, and/or system 118, and further determining how many of those referrals are made to other practitioners within the same network. In an embodiment, office billing 124 referral capture may be calculated based on a proportion of referrals made by practitioners within a certain office billing 124 group that are made to other practitioners within the same office billing 124 group. In a further embodiment, procedure billing 122 referral capture may be calculated based on a proportion of referrals made by practitioners billing under a certain procedure billing 122 group that are made to other practitioners within the same procedure billing 122 group. Additionally, capture metrics may be calculated to identify a proportion of referrals made to practitioners 102 within a certain clinic 106, group 114, facility 110, and/or system 118 that materialize into actual patient procedures.
The process flow 700 illustrated in FIG. 7 is similar to the process flow 600 illustrated in FIG. 6, with the exception of being directed to “referrals to” relationships rather than “referrals from” relationships. The process flow 700 can be used to identify and quantify to which performing healthcare entities a referring healthcare entity is referring work.
The process flow 700 includes determining aggregated claims over a time period 702. The aggregated claims may be selected based on any suitable metric depending on the application. In an example implementation, the aggregated claims include all claims processed by a hospital or other facility over some time period. In a further example implementation, the aggregated claims include all claims processed by a group 114 and/or system 118 over a time period. Further, the aggregated claims may include all claims processed through a certain healthcare network such as Medicare, Medicaid, or a private healthcare network over a time period. The aggregated claims may include all claims processed by numerous healthcare networks within a certain geographic region over a time period. It should be appreciated that the claims may be aggregated in any suitable manner depending on the application. The claims may include carrier claims 402 and/or facility claims 404. The claims may be associated with a single healthcare entity or with a plurality of healthcare entities.
The process flow 700 includes identifying referring identifiers 418 across the aggregated claims. This may include referring practitioners 604, referring clinics 706, and/or referring facilities 708, as applicable. The process flow 700 may include calculating a proportion of referrals provided by each referring practitioner ID 710, a proportion of referrals provided by each referring clinic ID 712, and/or a proportion of referrals provided by each referring facility ID 714. The process flow 700 may further include rolling proportions up to hierarchal healthcare entities such as clinics, facilities, groups, and systems, as applicable.
“Referrals to” represent the referrals one referring healthcare entity sends to other performing healthcare entities. This is the amount of business the referring healthcare entity is sending out to other performing healthcare entities. The logic applies when linking other healthcare entities by referral.
The “referrals to” metric may be used to calculate the referrals to proportions metric and the referrals to concentration metric. The referrals to proportions metric includes, for all referring healthcare entities, the proportion of their referrals going to other specific performing healthcare entities. This metric represents multiple measures, one for each pairing of referring/performing healthcare entities. The referrals to concentration metric includes, for all referring healthcare entities, a score summarizing the concentration of their specific referrals to proportions (specifically, sum of squared proportions). This may be done for each referring healthcare entity.
In an embodiment, a process for calculating “referrals to” metrics includes the following. First, claims data over a time period is aggregated. The claims data may include carrier claims 402 and/or facility claims 404. The claims data is analyzed to identify all referring healthcare entities based on the referring identifiers 418 included in the claims data. claims data is further analyzed to identify all performing healthcare entities based on the identifiers included in the claims data as a billing entity. It should be noted that a single claim may include a plurality of performing healthcare entities. The process includes calculating a proportion of business going from each referring healthcare entity to the other claim participants. The other claim participants may be grouped as follows: (a) one proportion for clinic billing on carrier claims and facility billing on facility claims; and (b) another proportion calculated for other practitioners. When multiple practitioners 102 appear on a claim, the claim will be divided to avoid double counting the claim. For example, if there are different attending, operating, and rendering practitioners 102 on a facility claim 404, the referring healthcare entity will be counted as referring one third of a claim to each of the three participating practitioners 102. These proportions can be rolled up to clinics 106, facilities 110, groups 114, and systems 118, as applicable, to represent the proportions of the referring healthcare entity's referrals going to the performing healthcare entity. Additionally, these proportions may be rolled up the referring side to calculate referrals to the performing healthcare entities from each referring healthcare entity's clinic 106, facility 110, group 114, and/or system 118.
In an embodiment, the process includes calculating referral metrics by line item on a billed claim. In an example, a billed claim includes four part performing healthcare entities. One quarter (25%) of the referral can be thought of as going to each of the four performing entities for purposes of this analysis.
FIG. 8 is a schematic flow chart diagram of a method 800 for calculating cohesion metrics between healthcare entities. FIG. 8 may be particularly drawn to calculating one or more of the referrals to proportions, referrals to concentration, referrals from proportions, or referrals from concentration. The method 800 illustrated in FIG. 8 may additionally be used to calculate further metrics related to referral patterns between healthcare entities. The method 800 may be performed by any suitable computing device and may be performed by one or more processors configurable to execute instructions stored in non-transitory computer readable storage media. The method 800 may be performed by one or more computing devices that may be in communication with one another.
The method 800 begins and a computing resource determines at 802 a plurality of billed claims. The billed claims may include carrier claims 402 and/or facility claims 404. The plurality of billed claims may be billed, processed, paid, or otherwise rendered during a certain time period. The plurality of billed claims may be associated with a certain practitioner 102, clinic 106, facility 110, group 114, system 118, healthcare payer, geographic region, and so forth. In an embodiment, the plurality of billed claims are processed by or provided to a certain healthcare payer such as Medicare, Medicaid, or a private healthcare payer, over a time period. In an embodiment, the plurality of billed claims are processed by various entities within a geographic region over a time period. It should be appreciated that the plurality of billed claims may be gathered and aggregated based on any suitable metric as determined based on the application.
The method 800 continues and a computing resource identifies at 804 one or more unique performing healthcare entities included in at least one of the plurality of billed claims. A performing healthcare entity may include a practitioner 102, clinic 106, facility 110, and so forth, as applicable. There may be a plurality of unique performing healthcare entities performing procedures across the plurality of billed claims. A single billed claim may include one or more performing healthcare entities.
The method 800 continues and a computing resource identifies at 806 one or more unique referring identifiers included in at least one of the plurality of billed claims. Each of the one or more unique referring identifiers is associated with a referring healthcare entity such as a practitioner 102, clinic 106, facility 110, group 114, system 118, and so forth. One billed claim may include one or more unique referring identifiers. One billed claim may include a plurality of line item services and procedures, and the unique referring identifiers may be associated with certain line items on the billed claim.
The method 800 continues and a computing resource calculates at 808, for at least one of the one or more unique performing healthcare entities, a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims. These proportions may be calculated for each referring/performing healthcare entity pair. These proportions may be used to calculate, for example, referrals to proportions, referrals to concentration, referrals from proportions, or referrals from concentration, and other metrics.
Referring now to FIG. 9, a block diagram of an example computing device 900 is illustrated. Computing device 900 may be used to perform various procedures, such as those discussed herein. Computing device 900 can perform various monitoring functions as discussed herein, and can execute one or more application programs, such as the application programs or functionality described herein. Computing device 900 can be any of a wide variety of computing devices, such as a desktop computer, in-dash computer, vehicle control system, a notebook computer, a server computer, a handheld computer, tablet computer and the like.
Computing device 900 includes one or more processor(s) 904, one or more memory device(s) 904, one or more interface(s) 906, one or more mass storage device(s) 908, one or more Input/output (I/O) device(s) 910, and a display device 930 all of which are coupled to a bus 912. Processor(s) 904 include one or more processors or controllers that execute instructions stored in memory device(s) 904 and/or mass storage device(s) 908. Processor(s) 904 may also include various types of computer-readable media, such as cache memory.
Memory device(s) 904 include various computer-readable media, such as volatile memory (e.g., random access memory (RAM) 914) and/or nonvolatile memory (e.g., read-only memory (ROM) 916). Memory device(s) 904 may also include rewritable ROM, such as Flash memory.
Mass storage device(s) 908 include various computer readable media, such as magnetic tapes, magnetic disks, optical disks, solid-state memory (e.g., Flash memory), and so forth. As shown in FIG. 9, a particular mass storage device 908 is a hard disk drive 924. Various drives may also be included in mass storage device(s) 908 to enable reading from and/or writing to the various computer readable media. Mass storage device(s) 908 include removable media 926 and/or non-removable media.
I/O device(s) 910 include various devices that allow data and/or other information to be input to or retrieved from computing device 900. Example I/O device(s) 910 include cursor control devices, keyboards, keypads, microphones, monitors or other display devices, speakers, printers, network interface cards, modems, and the like.
Display device 930 includes any type of device capable of displaying information to one or more users of computing device 900. Examples of display device 930 include a monitor, display terminal, video projection device, and the like.
Interface(s) 906 include various interfaces that allow computing device 900 to interact with other systems, devices, or computing environments. Example interface(s) 906 may include any number of different network interfaces 920, such as interfaces to local area networks (LANs), wide area networks (WANs), wireless networks, and the Internet. Other interface(s) include user interface 918 and peripheral device interface 922. The interface(s) 906 may also include one or more user interface elements 918. The interface(s) 906 may also include one or more peripheral interfaces such as interfaces for printers, pointing devices (mice, track pad, or any suitable user interface now known to those of ordinary skill in the field, or later discovered), keyboards, and the like.
Bus 912 allows processor(s) 904, memory device(s) 904, interface(s) 906, mass storage device(s) 908, and I/O device(s) 910 to communicate with one another, as well as other devices or components coupled to bus 912. Bus 912 represents one or more of several types of bus structures, such as a system bus, PCI bus, IEEE bus, USB bus, and so forth.

Examples

The following examples pertain to further embodiments.
Example 1 is a method. The method includes determining a plurality of billed claims. The method includes identifying one or more unique performing healthcare entities included in at least one of the plurality of billed claims. The method includes identifying one or more unique referring identifiers included in at least one of the plurality of billed claims. The method includes for at least one of the one or more unique performing healthcare entities, calculating a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims.
Example 2 is a method as in Example 1, wherein the one or more unique performing healthcare entities comprises a healthcare practitioner, and wherein the one or more unique referring identifiers comprises one or more of a practitioner identifier, a clinic identifier, or a facility identifier.
Example 3 is a method as in any of Examples 1-2, wherein identifying the healthcare practitioner of the one or more unique performing healthcare entities comprises identifying based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner, wherein the individual NPI is included in at least one of the plurality of billed claims.
Example 4 is a method as in any of Examples 1-3, further comprising one or more of: for each of the one or more unique referring identifiers comprising a unique practitioner identifier, identifying a healthcare group and/or healthcare system associated with the unique practitioner identifier; for each of the one or more unique referring identifiers comprising a unique clinic identifier, identifying a healthcare group associated with the unique clinic identifier; or for each of the one or more unique referring identifiers comprising a unique facility identifier, identifying a healthcare system associated with the unique facility identifier.
Example 5 is a method as in any of Examples 1-4, wherein one or more of: identifying the healthcare group and/or the healthcare system associated with the unique practitioner identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique practitioner identifier; identifying the healthcare group associated with the unique clinic identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique clinic identifier; or identifying the healthcare system associated with the unique facility identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique facility identifier.
Example 6 is a method as in any of Examples 1-5, wherein the one or more unique performing healthcare entities comprises one or more of: a healthcare practitioner identified based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner and included in at least one of the plurality of billed claims; a healthcare clinic identified based on an organization NPI associated with the healthcare clinic and included in at least one of the plurality of billed claims; or a healthcare facility identified based on a Centers for Medicare and Medicaid Services Certification Number (CCN) associated with the healthcare facility and included in at least one of the plurality of billed claims.
Example 7 is a method as in any of Examples 1-6, wherein the plurality of billed claims comprises carrier claims billed by a certain healthcare practitioner over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare practitioner, and wherein the method further comprises: calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by a certain referring practitioner of the one or more unique referring identifiers; rolling the certain referring practitioner up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of: a healthcare clinic; a healthcare facility; a healthcare group; or a healthcare system; and calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by the hierarchal healthcare entity.
Example 8 is a method as in any of Examples 1-7, wherein the plurality of billed claims comprises facility claims billed by a certain healthcare facility over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare facility, and wherein the method further comprises: calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by a certain referring identifier of the one or more unique referring identifiers; rolling the certain referring identifier up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of: a healthcare clinic; a healthcare facility; a healthcare group; or a healthcare system; and calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by the hierarchal healthcare entity.
Example 9 is a method as in any of Examples 1-8, wherein: identifying the one or more unique performing healthcare entities comprises identifying a plurality of performing healthcare practitioners on a single billed claim; identifying the one or more unique referring identifiers comprises identifying a certain referring identifier on the single billed claim; and the method further comprises proportioning the certain referring identifier among the plurality of performing healthcare practitioners on the single billed claim such that the certain referring identifier is calculated as referring only a portion of the single billed claim for each of the plurality of performing healthcare practitioners.
Example 10 is a method as in any of Examples 1-9, further comprising, for at least one of the one or more unique referring identifiers, calculating a proportion of referrals going to each of the one or more unique performing healthcare entities over the plurality of billed claims.
Example 11 is a system comprising one or more processors for executing instructions stored in non-transitory computer readable storage media, wherein the instructions comprise any of the method steps in Examples 1-10.
Example 12 is non-transitory computer readable storage media storing instructions for execution by one or more processors, wherein the instructions comprise any of the method steps in Examples 1-10.
In the above disclosure, reference has been made to the accompanying drawings, which form a part hereof, and in which is shown by way of illustration specific implementations in which the disclosure may be practiced. It is understood that other implementations may be utilized, and structural changes may be made without departing from the scope of the present disclosure. References in the specification to “one embodiment,” “an embodiment,” “an example embodiment,” etc., indicate that the embodiment described may include a particular feature, structure, or characteristic, but every embodiment may not necessarily include the particular feature, structure, or characteristic. Moreover, such phrases are not necessarily referring to the same embodiment. Further, when a particular feature, structure, or characteristic is described in connection with an embodiment, it is submitted that it is within the knowledge of one skilled in the art to affect such feature, structure, or characteristic in connection with other embodiments whether or not explicitly described.
Implementations of the systems, devices, and methods disclosed herein may comprise or utilize a special purpose or general-purpose computer including computer hardware, such as, for example, one or more processors and system memory, as discussed herein. Implementations within the scope of the present disclosure may also include physical and other computer-readable media for carrying or storing computer-executable instructions and/or data structures. Such computer-readable media can be any available media that can be accessed by a general purpose or special purpose computer system. Computer-readable media that store computer-executable instructions are computer storage media (devices). Computer-readable media that carry computer-executable instructions are transmission media. Thus, by way of example, and not limitation, implementations of the disclosure can comprise at least two distinctly different kinds of computer-readable media: computer storage media (devices) and transmission media.
Computer storage media (devices) includes RAM, ROM, EEPROM, CD-ROM, solid state drives (“SSDs”) (e.g., based on RAM), Flash memory, phase-change memory (“PCM”), other types of memory, other optical disk storage, magnetic disk storage or other magnetic storage devices, or any other medium, which can be used to store desired program code means in the form of computer-executable instructions or data structures and which can be accessed by a general purpose or special purpose computer.
An implementation of the devices, systems, and methods disclosed herein may communicate over a computer network. A “network” is defined as one or more data links that enable the transport of electronic data between computer systems and/or modules and/or other electronic devices. When information is transferred or provided over a network or another communications connection (either hardwired, wireless, or a combination of hardwired or wireless) to a computer, the computer properly views the connection as a transmission medium. Transmissions media can include a network and/or data links, which can be used to carry desired program code means in the form of computer-executable instructions or data structures and which can be accessed by a general purpose or special purpose computer. Combinations of the above should also be included within the scope of computer-readable media.
Computer-executable instructions comprise, for example, instructions and data which, when executed at a processor, cause a general-purpose computer, special purpose computer, or special purpose processing device to perform a certain function or group of functions. The computer executable instructions may be, for example, binaries, intermediate format instructions such as assembly language, or even source code. Although the subject matter has been described in language specific to structural features and/or methodological acts, it is to be understood that the subject matter defined in the appended claims is not necessarily limited to the described features or acts described above. Rather, the described features and acts are disclosed as example forms of implementing the claims.
Those skilled in the art will appreciate that the disclosure may be practiced in network computing environments with many types of computer system configurations, including, an in-dash vehicle computer, personal computers, desktop computers, laptop computers, message processors, hand-held devices, multi-processor systems, microprocessor-based or programmable consumer electronics, network PCs, minicomputers, mainframe computers, mobile telephones, PDAs, tablets, pagers, routers, switches, various storage devices, televisions, and the like. The disclosure may also be practiced in distributed system environments where local and remote computer systems, which are linked (either by hardwired data links, wireless data links, or by a combination of hardwired and wireless data links) through a network, both perform tasks. In a distributed system environment, program modules may be located in both local and remote memory storage devices.
Further, where appropriate, functions described herein can be performed in one or more of: hardware, software, firmware, digital components, or analog components. For example, one or more application specific integrated circuits (ASICs) can be programmed to carry out one or more of the systems and procedures described herein. Certain terms are used throughout the description and claims to refer to particular system components. The terms “modules” and “components” are used in the names of certain components to reflect their implementation independence in software, hardware, circuitry, sensors, or the like. As one skilled in the art will appreciate, components may be referred to by different names. This document does not intend to distinguish between components that differ in name, but not function.
It should be noted that the sensor embodiments discussed above may comprise computer hardware, software, firmware, or any combination thereof to perform at least a portion of their functions. For example, a sensor may include computer code configured to be executed in one or more processors and may include hardware logic/electrical circuitry controlled by the computer code. These example devices are provided herein purposes of illustration and are not intended to be limiting. Embodiments of the present disclosure may be implemented in further types of devices, as would be known to persons skilled in the relevant art(s).
At least some embodiments of the disclosure have been directed to computer program products comprising such logic (e.g., in the form of software) stored on any computer useable medium. Such software, when executed in one or more data processing devices, causes a device to operate as described herein.
While various embodiments of the present disclosure have been described above, it should be understood that they have been presented by way of example only, and not limitation. It will be apparent to persons skilled in the relevant art that various changes in form and detail can be made therein without departing from the spirit and scope of the disclosure. Thus, the breadth and scope of the present disclosure should not be limited by any of the above-described exemplary embodiments but should be defined only in accordance with the following claims and their equivalents. The foregoing description has been presented for the purposes of illustration and description. It is not intended to be exhaustive or to limit the disclosure to the precise form disclosed. Many modifications and variations are possible in light of the above teaching. Further, it should be noted that any or all the aforementioned alternate implementations may be used in any combination desired to form additional hybrid implementations of the disclosure.
Further, although specific implementations of the disclosure have been described and illustrated, the disclosure is not to be limited to the specific forms or arrangements of parts so described and illustrated. The scope of the disclosure is to be defined by the claims appended hereto, any future claims submitted here and in different applications, and their equivalents.

Claims

What is claimed is:

1. A method comprising:

determining a plurality of billed claims;

identifying one or more unique performing healthcare entities included in at least one of the plurality of billed claims;

identifying one or more unique referring identifiers included in at least one of the plurality of billed claims;

for at least one of the one or more unique performing healthcare entities, calculating a proportion of referrals coming from each of the one or more unique referring identifiers over the plurality of billed claims.

2. The method of claim 1, wherein the one or more unique performing healthcare entities comprises a healthcare practitioner, and wherein the one or more unique referring identifiers comprises one or more of a practitioner identifier, a clinic identifier, or a facility identifier.

3. The method of claim 2, wherein identifying the healthcare practitioner of the one or more unique performing healthcare entities comprises identifying based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner, wherein the individual NPI is included in at least one of the plurality of billed claims.

4. The method of claim 2, further comprising one or more of:

for each of the one or more unique referring identifiers comprising a unique practitioner identifier, identifying a healthcare group and/or healthcare system associated with the unique practitioner identifier;

for each of the one or more unique referring identifiers comprising a unique clinic identifier, identifying a healthcare group associated with the unique clinic identifier; or

for each of the one or more unique referring identifiers comprising a unique facility identifier, identifying a healthcare system associated with the unique facility identifier.

5. The method of claim 4, wherein one or more of:

identifying the healthcare group and/or the healthcare system associated with the unique practitioner identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique practitioner identifier;

identifying the healthcare group associated with the unique clinic identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique clinic identifier; or

identifying the healthcare system associated with the unique facility identifier comprises referencing a Provider Enrollment, Chain and Ownership System (PECOS) enrollment database comprising enrollment information for the unique facility identifier.

6. The method of claim 1, wherein the one or more unique performing healthcare entities comprises one or more of:

a healthcare practitioner identified based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner and included in at least one of the plurality of billed claims;

a healthcare clinic identified based on an organization NPI associated with the healthcare clinic and included in at least one of the plurality of billed claims; or

a healthcare facility identified based on a Centers for Medicare and Medicaid Services Certification Number (CCN) associated with the healthcare facility and included in at least one of the plurality of billed claims.

7. The method of claim 1, wherein the plurality of billed claims comprises carrier claims billed by a certain healthcare practitioner over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare practitioner, and wherein the method further comprises:

calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by a certain referring practitioner of the one or more unique referring identifiers;

rolling the certain referring practitioner up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:

a healthcare clinic;

a healthcare facility;

a healthcare group; or

a healthcare system; and

calculating a proportion of the carrier claims billed by the certain healthcare practitioner over the time period that were referred by the hierarchal healthcare entity.

8. The method of claim 1, wherein the plurality of billed claims comprises facility claims billed by a certain healthcare facility over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare facility, and wherein the method further comprises:

calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by a certain referring identifier of the one or more unique referring identifiers;

rolling the certain referring identifier up to a hierarchal healthcare entity, wherein the hierarchal healthcare entity comprises one of:

a healthcare clinic;

a healthcare facility;

a healthcare group; or

a healthcare system; and

calculating a proportion of the facility claims billed by the certain healthcare facility over the time period that were referred by the hierarchal healthcare entity.

9. The method of claim 1, wherein:

identifying the one or more unique performing healthcare entities comprises identifying a plurality of performing healthcare practitioners on a single billed claim;

identifying the one or more unique referring identifiers comprises identifying a certain referring identifier on the single billed claim; and

the method further comprises proportioning the certain referring identifier among the plurality of performing healthcare practitioners on the single billed claim such that the certain referring identifier is calculated as referring only a portion of the single billed claim for each of the plurality of performing healthcare practitioners.

10. The method of claim 1, further comprising, for at least one of the one or more unique referring identifiers, calculating a proportion of referrals going to each of the one or more unique performing healthcare entities over the plurality of billed claims.

11. A system comprising one or more processors for executing instructions stored in non-transitory computer readable storage media, the instructions comprising:

determining a plurality of billed claims;

12. The system of claim 11, wherein the one or more unique performing healthcare entities comprises a healthcare practitioner, and wherein the one or more unique referring identifiers comprises one or more of a practitioner identifier, a clinic identifier, or a facility identifier.

13. The system of claim 12, wherein the instructions are such that identifying the healthcare practitioner of the one or more unique performing healthcare entities comprises identifying based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner, wherein the individual NPI is included in at least one of the plurality of billed claims.

14. The system of claim 12, wherein the instructions further comprise one or more of:

15. The system of claim 14, wherein the instructions further comprise one or more of:

16. The system of claim 11, wherein the one or more unique performing healthcare entities comprises one or more of:

17. The system of claim 11, wherein the plurality of billed claims comprises carrier claims billed by a certain healthcare practitioner over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare practitioner, and wherein the instructions further comprise:

a healthcare clinic;

a healthcare facility;

a healthcare group; or

a healthcare system; and

18. The system of claim 11, wherein the plurality of billed claims comprises facility claims billed by a certain healthcare facility over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare facility, and wherein the instructions further comprise:

a healthcare clinic;

a healthcare facility;

a healthcare group; or

a healthcare system; and

19. The system of claim 11, wherein:

the instructions further comprise proportioning the certain referring identifier among the plurality of performing healthcare practitioners on the single billed claim such that the certain referring identifier is calculated as referring only a portion of the single billed claim for each of the plurality of performing healthcare practitioners.

20. The system of claim 11, wherein the instructions further comprise, for at least one of the one or more unique referring identifiers, calculating a proportion of referrals going to each of the one or more unique performing healthcare entities over the plurality of billed claims.

21. Non-transitory computer readable storage media storing instructions for execution by one or more processors, the instructions comprising:

determining a plurality of billed claims;

22. The non-transitory computer readable storage media of claim 21, wherein the one or more unique performing healthcare entities comprises a healthcare practitioner, and wherein the one or more unique referring identifiers comprises one or more of a practitioner identifier, a clinic identifier, or a facility identifier.

23. The non-transitory computer readable storage media of claim 22, wherein the instructions are such that identifying the healthcare practitioner of the one or more unique performing healthcare entities comprises identifying based on an individual National Provider Identifier (NPI) associated with the healthcare practitioner, wherein the individual NPI is included in at least one of the plurality of billed claims.

24. The non-transitory computer readable storage media of claim 22, wherein the instructions further comprise one or more of:

25. The non-transitory computer readable storage media of claim 24, wherein the instructions further comprise one or more of:

26. The non-transitory computer readable storage media of claim 21, wherein the one or more unique performing healthcare entities comprises one or more of:

27. The non-transitory computer readable storage media of claim 21, wherein the plurality of billed claims comprises carrier claims billed by a certain healthcare practitioner over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare practitioner, and wherein the instructions further comprise:

a healthcare clinic;

a healthcare facility;

a healthcare group; or

a healthcare system; and

28. The non-transitory computer readable storage media of claim 21, wherein the plurality of billed claims comprises facility claims billed by a certain healthcare facility over a time period, and wherein the one or more unique performing healthcare entities comprises the certain healthcare facility, and wherein the instructions further comprise:

a healthcare clinic;

a healthcare facility;

a healthcare group; or

a healthcare system; and

29. The non-transitory computer readable storage media of claim 21, wherein:

30. The non-transitory computer readable storage media of claim 21, wherein the instructions further comprise, for at least one of the one or more unique referring identifiers, calculating a proportion of referrals going to each of the one or more unique performing healthcare entities over the plurality of billed claims.