Computer-implemented method for grouping medical claims with clinically representative dynamic clean periods

Abstract

A computer-implemented method for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The method allows an objective means for measuring and quantifying health care services. An episode treatment group (ETG) is a patient classification unit, which defines groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. The ETG grouper methodology uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.

1 . A computer-implemented method for grouping medical claims data, comprising the steps of: a. grouping a plurality of medical claim data records to an episode of care; b. assigning a first clean period to the episode of care, the first clean period defined by a predefined time duration; and c. resetting the first clean period to define a second clean period, the second clean period defining a second predefined time duration, the resetting occurring based upon grouping of later presented medical claim data to the episode of care within the first clean period's predefined time duration.