Systems and methods for extraction of clinical knowledge with reimbursement potential

Abstract

A computerized Medical Information Navigation Engine (“MINE”) extracts clinical knowledge, by identifying coded elements with reimbursement potential contributing to payoff based on clinical history, and subtracting coded elements documented in an encounter from the coded elements, based on business logic. The MINE sorts the remaining coded elements in accordance with one optimization criteria to payoff based on clinical history.

What is claimed is: 
     
         1 . In a Medical Information Navigation Engine (“MINE”), a computerized method for clinical knowledge extraction, the method comprising;
 identifying a plurality of coded elements with reimbursement potential based on clinical history; 
 subtracting at least one coded element from the plurality of coded elements, wherein the subtracting is based on at least one business logic; 
 sorting a remainder of the plurality coded elements in accordance with at least one optimization criteria based on clinical history; and 
 providing the sorted remainder of the plurality of coded elements to a user. 
 
     
     
         2 . The computerized method of  claim 1  wherein the reimbursement potential includes at least one of contribution to payoff and previously rejected claims. 
     
     
         3 . The computerized method of  claim 2  wherein the rejected claims were rejected based on at least one of claim duplication, claim invalidity and improper claim format. 
     
     
         4 . The computerized method of  claim 1  wherein the at least one business logic includes at least one of encounter documentation, code hierarchy supersession and healthcare provider validation. 
     
     
         5 . The computerized method of  claim 1  wherein the at least one optimization criteria includes at least one of potential for payoff, contribution to patient risk and likelihood of accuracy. 
     
     
         6 . The computerized method of  claim 5  wherein the potential for payoff is derived from at least one potential reimbursement value. 
     
     
         7 . The computerized method of  claim 5  wherein the contribution to patient risk includes at least one patient risk adjustment factor (RAF). 
     
     
         8 . The computerized method of  claim 1  further comprising formatting the processed sorted remainder of the plurality of coded elements into a format acceptable by at least one of a payer and an auditor. 
     
     
         9 . The computerized method of  claim 1  wherein at least one of the processed sorted remainder of the plurality of coded elements has been validated by the user. 
     
     
         10 . The computerized method of  claim 1  further comprising tracking at least one of user presentation and user selection. 
     
     
         11 . The computerized method of  claim 1  further comprising storing the sorted remainder of the plurality of coded elements in a knowledge exchange for future rankings. 
     
     
         12 . A Medical Information Navigation Engine (“MINE”) configured to extract clinical knowledge for a user, the MINE comprising;
 a HCC knowledge provider configured to:
 identify a plurality of coded elements with reimbursement potential based on clinical history; 
 subtract at least one coded element from the plurality of coded elements, wherein the subtraction is based on at least one business logic; and 
 sort a remainder of the plurality coded elements in accordance with at least one optimization criteria based on clinical history; and 
 
 a user interface configured to provide the sorted remainder of the plurality of coded elements to a user. 
 
     
     
         13 . The MINE of  claim 12  wherein the reimbursement potential includes at least one of contribution to payoff and previously rejected claims. 
     
     
         14 . The MINE of  claim 13  wherein the rejected claims were rejected based on at least one of claim duplication, claim invalidity and improper claim format. 
     
     
         15 . The MINE of  claim 12  wherein the at least one business logic includes at least one of encounter documentation, code hierarchy supersession and healthcare provider validation. 
     
     
         16 . The MINE of  claim 12  wherein the at least one optimization criteria includes at least one of potential for payoff, contribution to patient risk and likelihood of accuracy. 
     
     
         17 . The MINE of  claim 16  wherein the potential for payoff is derived from at least one potential reimbursement value. 
     
     
         18 . The MINE of  claim 16  wherein the contribution to patient risk includes at least one patient risk adjustment factor (RAF). 
     
     
         19 . The MINE of  claim 12  wherein the HCC knowledge provider is further configured to format the processed sorted remainder of the plurality of coded elements into a format acceptable by at least one of a payer and an auditor. 
     
     
         20 . The MINE of  claim 12  wherein at least one of the processed sorted remainder of the plurality of coded elements has been validated by the user. 
     
     
         21 . The MINE of  claim 12  wherein the HCC knowledge provider is further configured to track at least one of user presentation and user selection. 
     
     
         22 . The MINE of  claim 12  further comprising a knowledge exchange configured to store the sorted remainder of the plurality of coded elements for future rankings. 
     
     
         23 . In a Medical Information Navigation Engine (“MINE”), a computerized method for hosting provider-guided educational material and top-of-mind concepts for patients, the method comprising;
 identifying at least one uncoded item in a patient clinical history; 
 matching the identified at least one uncoded item with a user hot list; 
 processing the matched and identified at least one uncoded item in a knowledge exchange; and 
 providing the processed matched identified at least one uncoded item to a user.