Systems, computer programs, and methods for controlling costs of a healthcare practice

Abstract

Systems, computer programs, and methods for controlling ancillary medical costs of a healthcare practice and/or insurance network with a plurality of physicians participating therein, are provided. According to an example method, the steps include identifying one or more a plurality of physicians having ancillary medical costs that exceed a certain level to thereby identify the physician or physicians for behavior modification with respect to ancillary medical costs. The method can also include generating information identifying recommended alternative ancillary medical procedures to modify behavior of a physician or physicians with respect to management of the ancillary medical costs. The method can also determining whether the ancillary medical costs of the physician or physicians have decreased to a preselected/baseline level, and distributing a percentage of a savings attributed to the modified ancillary medical cost management behavior when the ancillary medical costs have decreased to or below the preselected/baseline level.

1 . A method of controlling costs of a plurality of physicians in a healthcare practice participating in an insurance network, the method comprising the steps of:
 receiving, by a computer, data indicating ancillary medical costs attributed to a plurality of physicians in a healthcare practice participating in an insurance network;   identifying by the computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to ancillary medical costs to thereby reduce ancillary medical costs attributable to the respective one or more physicians;   generating information identifying recommended alternative ancillary medical procedures to modify behavior of the one or more of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs;   determining, by the computer, whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a preselected level; and   distributing a percentage of a savings attributed to the modified ancillary medical cost management behavior of the one or more of the plurality of physicians when the ancillary medical costs of the respective one or more of the plurality of physicians in the healthcare practice have decreased to or below the preselected level.   
     
     
         2 . A method as defined in  claim 1 , wherein the step of distributing the percentage of the savings includes:
 dividing the savings into selected percentages between at least two of the following: a healthcare consultation group providing ancillary medical cost management consultation services to the healthcare practice, the healthcare practice, and the insurance network; and   distributing the selected percentages of the savings to the at least two of the following: the healthcare consultation group, the healthcare practice, and the insurance network, based on the selected percentages.   
     
     
         3 . A method as defined in  claim 2 , further comprising the step of:
 collecting no fee by the healthcare consultation group if the healthcare practice does not reduce the ancillary medical costs to the preselected level.   
     
     
         4 . A method as defined in  claim 3 , wherein each of the respective predetermined percentages of the savings distributed to the healthcare consultation group and the healthcare practice are greater than the predetermined percentage of the savings distributed to the insurance network. 
     
     
         5 . A method as defined in  claim 4 , further comprising the step of:
 providing a billing fee structure from the healthcare consultation group; and   wherein the savings attributed to the modified ancillary medical cost management behavior of the one or more of the plurality of physicians are calculated by subtracting current ancillary medical costs from predetermined baseline ancillary medical costs.   
     
     
         6 . A method as defined in  claim 5 , further comprising the step of calculating the billing fee structure for the healthcare consultation group by multiplying a predetermined percentage of the savings by the number of patients participating in the healthcare practice. 
     
     
         7 . A method as defined in  claim 1 , wherein the preselected level comprises an ancillary medical costs baseline level. 
     
     
         8 . A method of controlling costs of a plurality of physicians in a healthcare practice participating in an insurance network, the method comprising the steps of:
 gathering, by a computer, data indicating ancillary medical costs attributed to a plurality of physicians in a healthcare practice participating in an insurance network;   identifying by the computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to ancillary medical costs to thereby reduce ancillary medical costs attributable to the respective one or more physicians and to increase profitability of the one or more of the plurality of physicians;   generating information identifying recommended alternative ancillary medical procedures to modify behavior of the one or more of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs;   determining, by the computer, whether the ancillary medical costs of the plurality of physicians in the healthcare practice have been reduced to or below a ancillary medical costs baseline; and   distributing a predetermined percentage of the savings attributed to the modified ancillary medical cost management behavior of the one or more of plurality of physicians if the ancillary medical costs have been reduced to or below the ancillary medical costs baseline.   
     
     
         9 . A method as defined in  claim 8 , wherein the step of modifying ancillary medical cost management behavior of one or more of the plurality of physicians comprises providing the respective one or more physicians behavior modification materials comprising information identifying recommended alternative ancillary medical procedures. 
     
     
         10 . A method as defined in  claim 9 , wherein the step of distributing the predetermined percentage of the savings includes:
 dividing the savings into selected percentages between at least two of the following: a healthcare consultation group providing ancillary medical cost management consultation services to the healthcare practice, the healthcare practice, and the insurance network; and   distributing the selected percentages of the savings to the at least two of the following: the healthcare consultation group, the healthcare practice, and the insurance network, based on the selected percentages.   
     
     
         11 . A method as defined in  claim 10 , further comprising the steps of collecting no fee by the healthcare consultation group if the healthcare practice does not reduce the ancillary medical costs to or below the ancillary medical costs baseline. 
     
     
         12 . A method as defined in  claim 11 , wherein each of the respective predetermined percentages of savings distributed to the healthcare consultation group and the healthcare practice are greater than the predetermined percentage of the savings distributed to the insurance network, and wherein the ancillary medical costs include any costs taken from the group of pharmacy, radiology, laboratory, anesthesiology, occupational therapy, physical therapy, speech therapy, therapeutic radiology, operating room, or emergency room costs. 
     
     
         13 . A method of controlling costs of an insurance network having a plurality of physicians in a healthcare practice participating therein, the method comprising the steps of:
 gathering, by a computer, data indicating ancillary medical costs attributed to a plurality of physicians in a healthcare practice participating in an insurance network;   identifying, by the computer, one or more of the plurality of physicians in the healthcare practice having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to ancillary medical costs to thereby reduce ancillary medical costs attributable to the respective one or more physicians to enhance profitability of the insurance network through control of ancillary medical costs;   generating information identifying recommended alternative ancillary medical procedures to modify behavior of the one or more of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs;   determining, by the computer, whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below a preselected level; and   distributing a predetermined percentage of a savings attributed to the modified ancillary medical cost management behavior of the one or more of the plurality of physicians to one or more of the following: the insurance network and a healthcare management consultation group providing ancillary medical cost management consultation services to the healthcare practice, when the ancillary medical costs have decreased to or below the preselected level.   
     
     
         14 . A method as defined in  claim 13 , wherein the step of distributing the predetermined percentage of the savings comprises distributing the predetermined percentage of the savings to the insurance network. 
     
     
         15 . A method as defined in  claim 13 , wherein the step of distributing the predetermined percentage of the savings comprises distributing the predetermined percentage of the savings to the healthcare management consultation group. 
     
     
         16 . A method as defined in  claim 13 , wherein the step of distributing the predetermined percentage of the savings includes:
 dividing the savings into selected percentages between at least two of the following: a healthcare consultation group, the healthcare practice, and the insurance network; and   distributing the selected percentages of the savings to the at least two of the following: the healthcare consultation group, the healthcare practice, and the insurance network, based on the selected percentages.   
     
     
         17 . A method as defined in  claim 16 , further comprising the step of collecting no fee by the healthcare consultation group if the modified medical management practices do not reduce the ancillary medical costs of the insurance network to or below the preselected level. 
     
     
         18 . A method as defined in  claim 16 , wherein each of the respective selected percentage of the savings distributed to the healthcare consultation group and the insurance network is greater than the selected percentage of the savings distributed to the healthcare practice. 
     
     
         19 . A method as defined in  claim 18 , further comprising the step of providing a billing fee structure from the healthcare consultation group wherein the savings are calculated by subtracting current ancillary medical costs from predetermined ancillary medical costs. 
     
     
         20 . A method as defined in  claim 19 , further comprising the step of calculating the billing fee structure for the healthcare consultation group by multiplying a percentage of the savings by the number of patients participating in the healthcare practice. 
     
     
         21 . A method as defined in  claim 13 , wherein the preselected level comprises an ancillary medical costs baseline. 
     
     
         22 . A method of controlling costs of a plurality of physicians in a healthcare practice participating in an insurance network, the method comprising the steps of:
 receiving, by a computer, data indicating ancillary medical costs attributed to a plurality of physicians in a healthcare practice participating in an insurance network;   identifying by the computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceeded a certain level during a preselected period of time to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to ancillary medical costs to thereby reduce ancillary medical costs attributable to the respective one or more physicians;   generating information identifying recommended alternative ancillary medical procedures to modify behavior of the one or more of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs;   determining, by the computer, whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have reached a preselected level; and   distributing a percentage of a savings attributed to the modified ancillary medical cost management behavior of the one or more of the plurality of physicians if the ancillary medical costs of the respective one or more of the plurality of physicians in the healthcare practice have reached the preselected level.   
     
     
         23 . A computer-assisted method of controlling costs of a plurality of physicians in a healthcare practice participating in an insurance network, the method comprising the steps of:
 providing a first computer associated with a tangible non-transitory computer readable medium and positioned to receive data indicating management of ancillary medical costs by a plurality of physicians in a healthcare practice participating in an insurance network;   receiving data by the first computer from at least one other computer associated with the plurality of physicians in the healthcare practice participating in the insurance network, the received data including ancillary medical costs attributed to the plurality of physicians;   identifying by the first computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to ancillary medical costs to increase profitability of the one or more of the plurality of physicians thereby reducing a risk of the healthcare practice not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance network;   generating information by the first computer identifying recommended alternative ancillary medical procedures to modify behavior of the one or more of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs;   determining by the first computer whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to or below baseline ancillary medical costs; and   calculating a percentage of a savings attributed to modified ancillary medical cost management behavior of the one or more of the plurality of physicians in the healthcare practice identified for behavior modification, for distribution to one or more of the following: the healthcare practice participating in the insurance network and the insurance network, when the ancillary medical costs of the respective one or more of the plurality of physicians in the healthcare practice have decreased to or below that of the baseline ancillary medical costs.   
     
     
         24 . A computer-assisted method of controlling costs of a plurality of physicians in a healthcare practice participating in an insurance network, the method comprising the steps of:
 providing a first computer associated with a tangible non-transitory computer readable medium and positioned to receive data indicating management of ancillary medical costs of a plurality of physicians in a healthcare practice participating in an insurance network;   receiving data by the first computer for the plurality of physicians in the healthcare practice participating in the insurance network, the received data including ancillary medical costs attributed to the respective physicians;   identifying by the first computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to management of ancillary medical costs;   generating information identifying recommended alternative ancillary medical procedures by the first computer to modify behavior of the one or more of the plurality of physicians in the healthcare practice identified for behavior modification with respect to management of the ancillary medical costs to thereby reduce a risk of the healthcare practice not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance network;   determining by the first computer whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice identified for behavior modification have decreased to a level that is at or below a preselected level; and   calculating a percentage of a savings attributed to modified ancillary medical cost management behavior of the one or more of the plurality of physicians in the healthcare practice identified for behavior modification, for distribution when the ancillary medical costs have decreased to a level that is at or below the preselected level.   
     
     
         25 . A computer-assisted method of enhancing profitability of an insurance network having a plurality of physicians in a healthcare practice participating in the insurance network, the method comprising the steps of:
 providing a first computer associated with a tangible non-transitory computer readable medium and positioned to receive data indicating management of ancillary medical costs of a plurality of physicians in a healthcare practice participating in an insurance network;   receiving data by the first computer from at least one other computer associated with the plurality of physicians, the received data indicating ancillary medical costs attributed to the plurality of physicians in the healthcare practice participating in the insurance network;   identifying by the first computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification;   generating information identifying alternative recommended ancillary medical practices by the first computer to modify the behavior of one or more of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs that is not preferred by the insurance network to thereby reduce ancillary medical costs attributed to the plurality of physicians to increase the insurance network's profitability;   determining by the first computer whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below a preselected level; and   calculating a percentage of savings attributed to modified ancillary medical costs management behavior of the one or more of the plurality of physicians in the healthcare practice identified for behavior modification, for distribution to one or more of the following: the insurance network and a healthcare management consultation group providing consultation services to the healthcare practice, when the ancillary medical costs have decreased to a level that is at or below the preselected level.   
     
     
         26 . A method as defined in  claim 25 , wherein the distribution of the percentage of savings is performed when the ancillary medical costs have decreased to a level at or below the preselected level over a preselected period of time. 
     
     
         27 . A computer-assisted method of controlling costs of an insurance network, the method comprising the steps of:
 providing a first computer associated with a tangible non-transitory computer readable medium and positioned to receive data indicating management of ancillary medical costs by a plurality of physicians in a healthcare practice participating in an insurance network;   receiving data by the first computer from at least one other computer associated with the plurality of physicians in the healthcare practice participating in the insurance network, the received data including ancillary medical costs attributed to at least one of the plurality of physicians,   identifying by the first computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network that have ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to ancillary medical costs;   generating information by the first computer identifying recommended alternative ancillary medical procedures with respect to management of the ancillary medical costs;   determining by the first computer whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below a preselected level;   calculating a percentage of a savings attributed to modified ancillary medical cost management behavior of the one or more of the plurality of physicians with respect to ancillary medical costs, for distribution to the healthcare practice participating in the insurance network when the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below the preselected level.   
     
     
         28 . A method as defined in  claim 27 , further comprising the step of:
 paying funds from a funded incentive pool to the healthcare practice participating in the insurance network when the ancillary medical costs of the plurality of physicians in the healthcare practice have not decreased to a level that is at or below the preselected level over a preselected period of time.   
     
     
         29 . A healthcare management system for controlling costs of a plurality of physicians in a healthcare practice participating in an insurance network, the system comprising:
 a computer to facilitate modifying ancillary medical cost management behavior of one or more of a plurality of physicians in a healthcare practice and to facilitate paying a percentage of savings attributed to modified ancillary medical cost management behavior of the one or more of plurality of physicians, the computer having a tangible storage medium for storing computer executable program code; and   computer executable program code stored on the storage medium of the computer and comprising a set of instructions that, when executed by the computer, cause the computer to perform the following operations:
 receiving data from at least one other computer associated with the plurality of physicians in the healthcare practice participating in the insurance network, the received data including data indicating ancillary medical costs attributed to at least one of the plurality of physicians, 
 identifying one or more of the plurality of physicians in the healthcare practice participating in the insurance network that have ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to ancillary medical costs, 
 generating information identifying recommended alternative ancillary medical procedures with respect to management of the ancillary medical costs, 
 determining whether the ancillary medical costs of the at least one of the plurality of physicians in the healthcare practice have decreased to a level that is at or below a preselected level, and 
 calculating a percentage of a savings attributed to the modified ancillary medical cost management of the one or more of the plurality of physicians, for distribution to the healthcare practice when the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below the preselected level. 
   
     
     
         30 . A system as defined in  claim 29 , wherein the preselected level comprises a baseline ancillary medical cost, and wherein the operations further comprise:
 distributing the preselected percentage of the savings attributed to the modified ancillary medical cost management of the one or more of the plurality of physicians when the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below the baseline ancillary medical cost.   
     
     
         31 . A healthcare management system for controlling costs of a plurality of physicians in a healthcare practice participating in an insurance network, the system comprising:
 a computer to facilitate modifying ancillary medical cost management behavior of one or more of a plurality of physicians in a healthcare practice and to facilitate paying a percentage of a savings attributed to modified ancillary medical cost management behavior of the one or more of the plurality of physicians in the healthcare practice, the computer having a tangible storage medium for storing computer executable program code; and   computer executable program code stored on the storage medium of the computer and comprising a set of instructions that, when executed by the computer, cause the computer to perform the following operations:
 receiving data for the plurality of physicians in the healthcare practice participating in the insurance network, the received data including data indicating ancillary medical costs attributed to at least one of the plurality of physicians, 
 identifying by the first computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to management of ancillary medical costs, 
 generating information identifying recommended alternative ancillary medical procedures with respect to management of the ancillary medical costs, 
 determining whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below the preselected level, and 
 calculating a percentage of a savings attributed to modified ancillary medical cost management of the one or more of the plurality of physicians, for distribution when the ancillary medical costs have decreased to the preselected level. 
   
     
     
         32 . A system as defined in  claim 31 , wherein the preselected level comprises a baseline ancillary medical cost, and wherein the operations further comprise:
 distributing the percentage of the savings attributed to the modified ancillary medical cost management behavior of the one or more of the plurality of physicians when the ancillary medical costs have decreased to a level that is at or below the baseline ancillary medical cost.   
     
     
         33 . A healthcare management system for enhancing profitability of an insurance network having a plurality of physicians in a healthcare practice participating in the insurance network, the system comprising:
 a computer configured to facilitate paying a percentage of a savings attributed to modified ancillary medical cost management behavior of one or more of the plurality of physicians, the computer having a tangible storage medium for storing computer executable program code; and   computer executable program code stored on the storage medium of the computer and comprising a set of instructions that, when executed by the computer, cause the computer to perform the following operations:
 receiving data from at least one other computer associated with the plurality of physicians, the received data indicating the ancillary medical costs attributed to at least one of the plurality of physicians in the healthcare practice participating in the insurance network, 
 identifying by the first computer one or more of the plurality of physicians in the healthcare practice participating in the insurance network having ancillary medical costs that exceed a certain level to thereby identify one or more of the plurality of physicians in the healthcare practice for behavior modification with respect to management of ancillary medical costs, 
 generating information identifying alternative recommended ancillary medical practices to modify behavior of the one or more of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs that is not preferred by the insurance network, 
 determining whether the ancillary medical costs of the one or more of the plurality of physicians in the healthcare practice have decreased to a level that is at or below a preselected level, 
 calculating a percentage of the savings attributed to modified ancillary medical costs management of the one or more of the plurality of physicians for distribution to one or more of the following: the insurance network and a healthcare management consultation group when the ancillary medical costs have decreased to a level that is at or below the preselected level. 
   
     
     
         34 . A system as defined in  claim 33 , wherein the preselected level comprises a baseline ancillary medical cost, and wherein the operations further comprise:
 distributing the percentage of the savings attributed to the modified ancillary medical cost management behavior of the one or more of the plurality of physicians when the ancillary medical costs have decreased to a level that is at or below the preselected level.