System and Method For Implementing Program Compliance For Health-Based Rewards

Abstract

A compliance process provides the ability to identify members that have completed a required activity for a Health Incentive Program (HIP) by comparing standard data such as claims, pharmacy, laboratory, biometric, health risk assessment and other pertinent internal and external data (hereafter “source data”) against established compliance criteria for that type of data for the specific HIP. If the member meets all compliance criteria within the designated timeframe, the member's achievement is recorded, resulting in the appropriate reward being granted as defined by the HIP. The compliance process solution provides an automated way for a payer to evaluate internal and/or external data including claims, pharmacy and/or biometric data to identify instances of a member completing required activities.

1 . A process for determining compliance with a health incentive program comprising;
 receiving at a processor member medical claims data from a first data source;   applying at least a first filter by the processor to the received member medical claims data to identify categories of interest within the member medical claims data;   providing member medical claims data in accordance with the identified categories of interest;   receiving an indicator that the member medical claims data is available for processing for member compliance with one or more health incentive programs;   determining by the processor if one or more health incentive programs applies to the member medical claims data in accordance with the categories of interest;   applying by the processor compliance rules to the member medical claims data for each applicable health incentive program to determine if a member has attained one or more achievement levels;   generating by the processor a new achievement record or an update to an existing achievement record for each of the one or more members if the one or more members have attained one or more achievement levels in accordance with the member medical claims data;   receiving by the processor member non-medical claims data from a second source indicating that one or more members have attained one or more achievement levels;   generating by the processor a new achievement record or an update to an existing achievement record for each of the one or more members in accordance with the one or more achievement levels attained in accordance with the non-medical claims data; and   making the achievement records available for processing by a reward generation component.   
     
     
         2 . The process according to  claim 1 , further comprising applying at least a second filter to the member medical claims data to determine claim date information prior to determining if one or more health incentive programs applies; wherein the claim date information is utilized to determine at least one of if one or more health incentive programs applies and if one or more members associated with the member health-related data has attained one or more achievement levels. 
     
     
         3 . The process according to  claim 1 , wherein the second source is a member or trusted external compliance source. 
     
     
         4 . The process according to  claim 1 , wherein processor compliance rules are applied to each row of received member medical claims data to determine if multiple achievement levels have been attained by a member. 
     
     
         5 . The process according to  claim 1 , further comprising determining by the reward generation component, the one or more member's reward and applying the reward to the member. 
     
     
         6 . The process according to  claim 5 , wherein applying the reward to the member includes automatically reducing an amount owed by the member under the member's medical plan. 
     
     
         7 . The process according to  claim 6 , wherein the automatic reduction is selected from a reduction in co-insurance and a reduction in co-payment. 
     
     
         8 . The process according to  claim 1 , wherein the one or more achievement levels are associated with at least one of: a member attaining a biometric goal; a member completing a health assessment; a member obtaining a medical test; a member completing a health-related educational course; a member completing a course of medical treatment; and a member completing self reporting of medical status requirements. 
     
     
         9 . The process according to  claim 1 , further comprising determining by the processor the eligibility of the one or more members in the one more health incentive programs prior to generating one of a new achievement record or updating an existing achievement record for the one or more members. 
     
     
         10 . The process according to  claim 1 , wherein providing member medical claims data in accordance with the identified categories of interest includes populating by the processor a staging table with the member medical claims data in accordance with the identified categories of interest.