U.S. patent application number 14/270139 was filed with the patent office on 2014-08-28 for outcomes based service provider networks.
This patent application is currently assigned to HARTFORD FIRE INSURANCE COMPANY. The applicant listed for this patent is HARTFORD FIRE INSURANCE COMPANY. Invention is credited to William J. Bohn, Robert E. Bonner, Joseph D. Pagano.
Application Number | 20140244291 14/270139 |
Document ID | / |
Family ID | 46163082 |
Filed Date | 2014-08-28 |
United States Patent
Application |
20140244291 |
Kind Code |
A1 |
Bonner; Robert E. ; et
al. |
August 28, 2014 |
OUTCOMES BASED SERVICE PROVIDER NETWORKS
Abstract
A system and method are provided for determining a composition
of a service provider network for providing services according to a
workers' compensation insurance plan. The system and method
acquires claim information, which describes workers' compensation
claims and medical service providers, and determines a metric value
for each of the medical service providers, adjusts the metric
values, assigns scores based on the adjusted metric values,
determines an average of the assigned scores, and generates results
data based on the assigned scores. The results data indicates, for
each of the medical service providers, whether the medical service
provider should be included in the service provider network. The
service provider metrics include a metric that relates to an amount
paid per claim and a percentage of claims that involved lost
time.
Inventors: |
Bonner; Robert E.;
(Hartford, CT) ; Pagano; Joseph D.; (Wallingford,
CT) ; Bohn; William J.; (West Hartford, CT) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
HARTFORD FIRE INSURANCE COMPANY |
Hartford |
CT |
US |
|
|
Assignee: |
HARTFORD FIRE INSURANCE
COMPANY
Hartford
CT
|
Family ID: |
46163082 |
Appl. No.: |
14/270139 |
Filed: |
May 5, 2014 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
12958704 |
Dec 2, 2010 |
8719058 |
|
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14270139 |
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Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G06Q 40/08 20130101;
G16H 40/20 20180101 |
Class at
Publication: |
705/2 |
International
Class: |
G06F 19/00 20060101
G06F019/00 |
Claims
1. A system for determining a composition of a service provider
network for providing services according to a workers' compensation
insurance plan, the system comprising: a computer-readable storage
medium, configured to store claim information, wherein the claim
information describes: workers' compensation claims; and medical
service providers that provided medical services related to the
workers' compensation claims; at least one processor, configured:
to determine, for each of the medical service providers, a metric
value for each of a plurality of service provider metrics based on
the claim information, wherein the service provider metrics
include: a metric that relates to an amount paid per claim; and a
percentage of claims that involved lost time; to adjust the metric
values based on one or more adjustment parameters; to assign scores
to each of the medical service providers based on the adjusted
metric values; to determine averages of the assigned scores for
each of the medical service providers; and to generate results data
based on the determined averages of the assigned scores, wherein
the results data indicates, for each of the medical service
providers, whether the medical service provider is included in the
service provider network; and a display device, configured to
display the results data.
2. The system of claim 1, wherein the service provider metrics
further include one or more of: an average number of disability
days; or a percentage of claims that involved legal activity.
3. The system of claim 1, wherein the service provider metrics
further include one or more of: an average claimant satisfaction;
an average claims adjuster satisfaction; or an average employer
satisfaction.
4. The system of claim 1, wherein the one or more adjustment
parameters include: a type of injury associated with claims handled
by the medical service provider; an age of claimants for claims
handled by the medical service provider; or an age of claims
handled by the medical service provider.
5. The system of claim 4, wherein the at least one processor is
configured to adjust the metric values based on the one or more
adjustment parameters by: determining an average metric value for
claims with a given type of injury; and adjusting the metric values
based on the determined average metric value.
6. The system of claim 4, wherein the at least one processor is
configured to adjust the metric values based on the one or more
adjustment parameters by: determining an average metric value for
claims with claimants of a given age; and adjusting the metric
values based on the determined average metric value.
7. The system of claim 4, wherein the at least one processor is
configured to adjust the metric values based on the one or more
adjustment parameters by: determining an average metric value for
claims of a given age; and adjusting the metric values based on the
determined average metric value.
8. The system of claim 1, wherein the at least one processor is
further configured to determine whether, for each of the medical
service providers, the medical service provider is included in the
service provider network or not based on whether the average of the
assigned scores for the medical service provider is above or below
a threshold value.
9. The system of claim 1, further comprising: at least one
communication interface, configured to receive one or more search
parameters that indicate a search for a medical service provider to
obtain medical services; wherein the at least one processor is
configured to generate search response information, wherein the
search response information includes information related to medical
service providers that are included in the service provider
network, and does not include information related to medical
service providers that are not included in the service provider
network; and wherein the at least one communication interface is
further configured to transmit the search response information.
10. The system of claim 1, wherein the at least one processor is
configured to assign the scores to each of the medical service
providers based on percentage ranges for each of the service
provider metrics and scores that correspond to each of the
percentage ranges, wherein the percentage ranges and corresponding
scores include: a percentage range of ninety percent to one hundred
percent, which corresponds to a score of five; a percentage range
of seventy-five percent to ninety percent, which corresponds to a
score of four; a percentage range of fifty percent to seventy-five
percent, which corresponds to a score of three; a percentage range
of twenty-five percent to fifty percent, which corresponds to a
score of two; a percentage range of ten percent to twenty-five,
which corresponds to a score of one; and a percentage range of zero
percent to ten percent, which corresponds to a score of zero.
11. A computer-implemented method for determining a composition of
a service provider network, the method comprising: a
computer-readable storage medium storing claim information, wherein
the claim information describes: workers' compensation claims; and
medical service providers that provided medical services related to
the workers' compensation claims; at least one processor
determining, for each of the medical service providers, a metric
value for each of a plurality of service provider metrics based on
the claim information, wherein the service provider metrics
include: a metric that relates to an amount paid per claim; and a
percentage of claims that involved lost time; the at least one
processor adjusting the metric values based on one or more
adjustment parameters; the at least one processor assigning scores
to each of the medical service providers based on the adjusted
metric values; the at least one processor determining averages of
the assigned scores for each of the medical service providers; and
the at least one processor generating results data based on the
determined averages of the assigned scores, wherein the results
data indicates, for each of the medical service providers, whether
the medical service provider is included in the service provider
network; and a display device displaying the results data.
12. The method of claim 11, wherein the service provider metrics
further include one or more of: an average number of disability
days; or a percentage of claims that involved legal activity.
13. The method of claim 11, wherein the service provider metrics
further include one or more of: an average claimant satisfaction;
an average claims adjuster satisfaction; or an average employer
satisfaction.
14. The method of claim 11, wherein the one or more adjustment
parameters include: a type of injury associated with claims handled
by the medical service provider; an age of claimants for claims
handled by the medical service provider; or an age of claims
handled by the medical service provider.
15. The method of claim 14, wherein the adjusting the metric values
based on the one or more adjustment parameters includes:
determining an average metric value for claims with a given type of
injury; and adjusting the metric values based on the determined
average metric value.
Description
CROSS REFERENCE TO RELATED APPLICATION
[0001] This application is a continuation of U.S. patent
application Ser. No. 12/958,704, filed Dec. 2, 2010, which is
incorporated by reference as if fully set forth.
TECHNICAL FIELD
[0002] The subject matter disclosed herein relates to computer
systems, and particularly to the storage, processing, and display
of data related to service provider networks.
BACKGROUND
[0003] Workers' compensation insurance is an insurance that
provides benefits to workers that are injured in the course of
their employment. Benefits that may be provided as part of workers'
compensation include disability benefits, rehabilitation services,
and medical care. An employer may purchase a workers' compensation
insurance policy from an insurance provider. The policy may
identify a network of service providers that treat the employees of
the employer according to the policy. Service providers may include
hospitals, doctors, and rehabilitation providers that administer
care to injured workers.
[0004] Service providers may vary in terms of the quality of care
that they provide to injured workers. For example, a service
provider may provide superior medical treatment versus other
service providers, and workers that receive care from the superior
service provider may consistently have better outcomes (i.e., may
recover from injuries more quickly) than workers who are treated by
other service providers.
[0005] To provide the best care possible to injured workers,
insurance providers and employers want the best possible service
providers to be included in their service provider networks.
However, it may be difficult for insurance providers and employers
to determine who the best service providers are. Therefore, new
technologies are required that may be used to assess the
effectiveness of service providers, such that the best possible
care may be provided to injured workers.
SUMMARY
[0006] Disclosed herein are technologies that may be used to
determine the composition of service provider networks. Service
providers may be compared based on a number of metrics related to
the services they provide. As an example, medical service providers
may be compared based on factors such as how quickly patients in
their care recover from injuries, and how satisfied patients are
with the care they receive. A service provider network may be
defined as including only service providers with metrics that meet
a given threshold. In the context of workers' compensation
insurance, the disclosed technologies may be used to direct injured
workers to medical service providers that provide superior care,
thereby achieving better outcomes for injured workers.
[0007] A system for determining a composition of a service provider
network for providing services according to a workers' compensation
insurance plan may include a computer-readable storage medium, at
least one processor, and a display device. The computer-readable
storage medium may store claim information. The claim information
may describe workers' compensation claims and the medical service
providers that provided medical services related to the workers'
compensation claims. The at least one processor may determine, for
each of the medical service providers, a metric value for each of a
number of service provider metrics. This may be based on the claim
information, and/or other factors. The service provider metrics may
include a metric that relates to an amount paid per claim or a
percentage of claims that involved lost time. The at least one
processor may adjust the metric values based on one or more metric
values. Further, the at least one processor may assign scores to
each of the medical service providers based on the adjusted metric
values, and may determine averages for the assigned scores for each
of the medical service providers. Further, the at least one
processor may generate results data based on the determined
averages of the assigned scores. The results data may indicate, for
each of the medical service providers, whether the medical service
provider is included in the service provider network. The display
device may display the results data.
[0008] A computer-implemented method for determining a composition
of a service provider network may include a computer-readable
storage storing claim information. The claim information may
describe workers' compensation claims and the medical service
providers that provided medical services related to the workers'
compensation claims. At least one processor may determine, for each
of the medical service providers, a metric value for each of a
number of service provider metrics. This may be based on the claim
information, and/or other factors. The service provider metrics may
include a metric that relates to an amount paid per claim or a
percentage of claims that involved lost time. The at least one
processor may adjust the metric values based on one or more metric
values, may assign scores to each of the medical service providers
based on the adjusted metric values, and may determine averages for
the assigned scores for each of the medical service providers.
Further, the at least one processor may generate results data based
on the determined averages of the assigned scores. The results data
may indicate, for each of the medical service providers, whether
the medical service provider is included in the service provider
network. The results data may then be displayed by a display
device.
[0009] A computer-readable medium may store processor-executable
instructions which, when executed by at least one processor, will
cause the at least one processor to perform a method for
determining a composition of a service provider network. The method
may include the at least one processor receiving claim information.
The claim information may describe workers' compensation claims and
the medical service providers that provided medical services
related to the workers' compensation claims. The at least one
processor may determine, for each of the medical service providers,
a metric value for each of a number of service provider metrics.
This may be based on the claim information, and/or other factors.
The service provider metrics may include a metric that relates to
an amount paid per claim or a percentage of claims that involved
lost time. The at least one processor may adjust the metric values
based on one or more metric values, may assign scores to each of
the medical service providers based on the adjusted metric values,
and may determine averages for the assigned scores for each of the
medical service providers. Further, the at least one processor may
generate results data based on the determined averages of the
assigned scores. The results data may indicate, for each of the
medical service providers, whether the medical service provider is
included in the service provider network. The at least one
processor may then display the results data via a display
device.
BRIEF DESCRIPTION OF THE DRAWINGS
[0010] A more detailed understanding may be had from the following
description, given by way of example in conjunction with the
accompanying drawings wherein:
[0011] FIG. 1 shows an example architecture 100 for determining the
composition of a service provider network;
[0012] FIG. 2 shows an example method for determining the
composition of a service provider network;
[0013] FIG. 3 shows an example graph that shows a function that may
be used for normalizing data in the context of determining the
composition of a service provider network;
[0014] FIG. 4 shows a second example graph that may be used for
normalizing data in the context of determining the composition of a
service provider network;
[0015] FIG. 5 shows an example user interface element that that may
be used to display data that describes the composition of a service
provider network; and
[0016] FIG. 6 shows an example system that may be used to implement
the features described herein with reference to FIGS. 1-5.
DETAILED DESCRIPTION
[0017] FIG. 1 shows an example architecture 100 for determining the
composition of a service provider network for use in the context of
workers' compensation insurance. As will be describe in further
detail below, the example architecture 100 of FIG. 1 may be used to
determine if specific service providers should be included in a
service provider network, and/or to determine how service providers
within a network should be ranked or classified.
[0018] The example architecture 100 includes a network determining
module 110, which is configured to analyze data and determine the
composition of a service provider network. The example architecture
100 may also includes a claim information database 122, claim
information database module 120, and a data input module 124, which
perform functionality related to the storage of data that describes
services that have been provided to users by service providers.
Further, the example architecture 100 may include a service
provider search module 130, service provider network database 132,
and a search client module 134, which together provide data to
users about medical services providers from which the users may
receive services.
[0019] The claim information database 122 may be stored on one or
any number of computer-readable storage media (not depicted). The
claim information database 122 may be or include, for example, a
relational database, a hierarchical database, an object-oriented
database, one or more flat files, one or more spreadsheets, and/or
one or more structured files. The claim information database 122
may store information related to claims that have been filed and
medical service providers that have provided services related to
the claims. The claim information database 122 may include data
related to service providers who are already included in one or
more service provider networks, service providers who are not
currently in a service provider network, and/or any combination
thereof. For each claim, the claim information database 122 may
include one or more parameters associated with the claim, such as:
the amount paid by the insurance provider for the claim; the number
of disability days for which the claimant missed work; whether the
claim is associated with litigation or other legal activity; the
number of days the claim has stayed open, which may also be
referred to as the "age" or "maturity" of a claim; whether the
claim settled; whether the compensability of the claim has been
determined (in other words, whether a determination has been that
the claim relates to an injury that should be compensated by
workers' compensation insurance, or whether investigation into this
topic is still ongoing); the number of service provider office
visits associated with the claim; whether surgery was associated
with the claim; whether inpatient hospitalization was associated
with the claim; the age of the claimant; a treatment delay time
(i.e., the period of time that passed between the injury and when
the claimant first sought treatment for the injury); a location
where the injury and/or the treatment took place; a service
provider that provided services associated with the claim; and/or
other information. Further, the claim information database 122 may
include information such as whether each claim involved lost time.
Many jurisdictions define a waiting period that follows the onset
of an injury. Work that is missed during this waiting period does
not constitute lost time; however, work that is missed by an
injured working after the waiting period is considered lost time.
Alternatively or additionally, the claim information database 122
may store qualitative information related to the claims, such as:
data that describes the satisfaction of the claimant with the care
received; data that describes the satisfaction of a claims adjuster
that handled the treatment associated with the claim with the
service provider; and/or information that describes the
satisfaction of the claimant's employer with how the service
provider handled the treatment associated with the claim. A level
of satisfaction may be represented using a numeric scale, with
different values along the scale corresponding to different levels
of satisfaction. As an example, a scale of zero to ten may be used,
wherein zero represents the lowest level of satisfaction and ten
represents the highest level of satisfaction).
[0020] The claim information database module 120 may perform
functionality such as adding data to, modifying data in, querying
data from, and/or retrieving data from the claim information
database 122. The claim information database module 120 may be, for
example, a database management system (DBMS), a database driver, a
module that perform file input/output operations, and/or other type
of module. The claim information database module 120 may be based
on a technology such as MICROSOFT SQL Server, MICROSOFT ACCESS,
MYSQL, POSTGRESQL, ORACLE RELATIONAL DATABASE MANAGEMENT SYSTEM
(RDBMS), MICROSOFT EXCEL, a NOSQL database technology, and/or any
other appropriate technology.
[0021] The data input module 124 may perform functionality such as
providing data to the claim information database module 120 for
storage in the claim information database 122. The data input
module 124 may be, for example, a spreadsheet program, a database
client application, a web browser, and/or any other type of
application that may be used to provide data to the claim
information database module 120.
[0022] The network determining module 110 may perform functionality
such as determining the composition of a service provider network
based on information stored in the claim information database 122.
The network determining module 110 may include an input module 112,
a network composition module 114, and an output module 116. The
input module 112 may perform functionality such as obtaining data
from the claim information database module 120 and providing the
data to the network composition module 144. The network composition
module 114 may perform functionality such as analyzing the data
provided by the input module 112 to determine the composition of
the service provider network. This may include, for example,
analyzing how well service providers perform in a number of
parameters (such as those described above as stored in the claim
information database 122), assigning scores to the service
providers based on their performances, and ranking service
providers based on their scores. The network composition module 114
may determine whether service providers should be included in a
service provider network or not, based on the scores. Alternatively
or additionally, the network composition module 114 may determine
that service providers within a certain range of scores may be
classified differently from service providers within other ranges.
For example, service providers with scores above a threshold value
should be classified as "preferred" providers within the network,
while providers with lower scores may not.
[0023] The output module 116 may obtain results determined by the
network composition module 114 and may output the results in a
number of ways. For example, the output module 116 may store the
results in one or more computer-readable media (not depicted),
and/or may send information related to the results to an output
device (not depicted) such as a printer, display device, or network
interface. Alternatively or additionally, the output module 116 may
transmit and/or otherwise output its results for storage in the
service provider network database 132. Further details regarding
functionality that may be performed by the network determining
module 110 are provided below with reference to FIG. 2.
[0024] The service provider network database 132 may store
information that describes the composition of a service provider
network. For example, the service provider network database 132 may
include information that identifies service providers in the
network, and may include contact information, specialty
information, geographic information, information regarding how well
service providers have been ranked by the network composition
module 114 (for example, whether providers are "preferred" or not),
and/or information associated with the service providers. The
service provider network database 132 may be stored on one or any
number of computer-readable storage media (not depicted). The claim
information database 122 may be or include, for example, a
relational database, a hierarchical database, an object-oriented
database, one or more flat files, one or more spreadsheets, and/or
one or more structured files.
[0025] The service provider search module 130 may provide search
functionality that allows users to search for service providers
whose information is stored in the service provider network
database 132. A user may interact with the service provider search
module 130 using the search client module 134. The search client
module 134 may provide a user interface that the user may use to
enter information to search for a service provider. As an example,
the search client module 134 may be a web browser or similar
application.
[0026] As an example, a user may wish to search for a medical
service provider for a particular medical specialty that is
geographically nearby to the user's location. The user may enter
these search parameters into the user provided by the search client
module 134, which may transmit the search parameters to the service
provider search module 130. The search parameters may include, for
example, an area of specialization, name, geographic location (such
as a state, city, and/or zip code), and/or other parameters. The
service provider search module 130 may then search for a service
provider in the service provider database 132 that matches the
parameters, and transmit search response information to the search
client module 134. The service provider search module 130 may
generate the results based on information such as how the service
providers have been ranked by the network composition module 114.
For example, the service provider search module 130 may generate
results that will display preferred providers before providers with
less favorable rankings are displayed. Alternatively or
additionally, the service provider search module 130 may generate
the search results to include only service providers within a
certain range of scores. The search client module 134 may then
display the search response information to the user via a display
device (not depicted). The search response information may include
contact information such as telephone numbers, addresses, and/or
other information related to the medical service providers that
match the search criteria. Using the contact information, the user
may contact the service providers and initiate a visit to the
service provider to begin medical treatment.
[0027] Each or any combination of the modules 110, 112, 114, 116,
124, 120, 130, 134 may be implemented as software modules,
specific-purpose processor elements, or as combinations thereof. A
suitable software module may be or include, by way of example, one
or more executable programs, one or more functions, one or more
method calls, one or more procedures, one or more routines or
sub-routines, one or more processor-executable instructions, and/or
one or more objects or other data structures.
[0028] The example architecture 100 of FIG. 1 may be used in any
number of different contexts. As one example, an insurance provider
may control the data input module 124, claim information database
module 120, claim information database 122, and network determining
module 110. The insurance provider may use these modules 110, 120,
124 to determine the composition of a service provider network for
use with a workers' compensation policy. The insurance provider may
provide the composition of the service provider network to a third
party search vendor, which may control the service provider search
module 130. The insurance provider may provide the workers'
compensation policy to an employer. When employees of the employer
are injured, the employees may search for medical service providers
using the search client module 134, thereby interacting with the
service provider search module 130.
[0029] As an additional example, a third party administrator (TPA)
of a self-funded workers' compensation plan may control the data
input module 124, claim information database module 120, claim
information database 122, and network determining module 110. The
TPA may use these modules 110, 120, 124 to determine the
composition of a service provider network for use with the
self-funded plan. The TPA and/or a third party search vendor may
control the service provider search module 130.
[0030] Further, an insurance provider or TPA may interact with
service providers differently based on the results generated by the
network determining module 110. For example, in an instance where
the network determining module 110 classifies service providers, an
insurance provider or TPA may perform claim management differently
with service providers that are in the different classifications.
For example, an insurance provider or TPA may reduce or completely
remove claim management for service providers with favorable
scores, while focusing additional energy and resources for claim
management for providers with less favorable scores.
[0031] FIG. 2 shows an example method 200 for determining the
composition of a service provider network. The method 200 may begin
with receiving data related to service providers and claims
associated with services provided by the service providers (step
202). This may include, for example, reading the data from a
computer-readable storage medium and/or receiving the data via a
network interface. The data may be or include the information
described above with reference to FIG. 1 as stored in the claim
information database 122.
[0032] Next, metrics for evaluating service providers may be
selected (step 204). The metrics may include, for example, an
average number of disability days experienced by workers that were
treated by a service provider, or a percentage of claims that
involved lost time. As further examples, the metrics may include:
an average paid loss per claim; a percentage of claims that are
associated with legal and/or litigation activity; an average claim
duration; a percentage of claims that are open after twelve months;
a percentage of claims for which compensability has not yet been
determined; a percentage of claims that were settled; an average
number of provider office visits for claims; a percentage of claims
that involve surgery; a percentage of claims that involve inpatient
hospitalization; an average number of lost work days per claim;
average levels of satisfaction with provided services, as indicated
by claimants, claims adjusters, and/or employers; and/or other
metrics. While a number of example metrics are described above in
terms of averages, the metrics may also include metrics that are
based on other statistical functions such as means, modes,
correlations, regressions, or standard deviations.
[0033] Claims may then be filtered, based on a number of different
parameters. (step 206). This may include removing data related to
claims that have parameters that are far above or below the average
for that parameter. For example, claims related to catastrophic
injuries may have much higher associated costs, disability days,
and/or higher values for other parameters, and data associated with
these claims may be removed. As one example, claims that involved
payment of more than a given threshold for a given type of expense
within a given period of time may be removed. For example, claims
that involved payment of more than $150,000 in medical expenses
within the first six months of the filing of the claim may be
removed. Alternatively or additionally, claims that involved a low
total payment may be removed. For example, claims that involved a
total payment of less than $50,000 may be filtered out of the
received data. Alternatively or additionally, filtering may include
removing data that is outside of a particular geographic area of
interest. For example, if a particular zip code, state, or other
geographic area is the region of interest, then claims that do not
pertain to the geographic area may be removed.
[0034] Then, for each metric, values may be determined for each of
the service providers, based on the received data (step 208). This
may include averaging and/or determining percentages for the data
from the received data that is associated with claims handled by
the service providers. For example, if a selected metric is an
average satisfaction level for claimants, then the claimant
satisfaction level values will be averaged for each service
provider. Corresponding processing may be performed for each of the
selected metrics.
[0035] The metric values may then be adjusted to obtain metric
values that are consistent values across service providers (step
210). Adjusting the metric values may include scaling and/or
otherwise modifying the metric values, and may be based on a number
of different factors. For example, metric values may be adjusted
based on one or more adjustment parameters, such as the types of
injuries a service provider has treated, the ages of claimants
handled by a service provider, and/or the ages of claims handled by
a service provider.
[0036] To adjust metric values based on the type of injuries a
service provider has treated (step 210), the following approach may
be employed. First, claims may be grouped according to the type of
injury (also referred to as the "Major Diagnostic Category (MDC)")
of the injury. Then, for each MDC, an average metric value for
claims associated with that MDC may be determined. Then, the
average metric values for each MDC may be compared, and values
("scaling factors") may be determined for each of the MDCs. Scaling
factors are values that may be used to multiply the average metric
values to bring the average metric values onto a common scale.
Finally, metric values may be multiplied by the scaling factors to
obtain adjusted metric values.
[0037] The following is an example of how metric values may be
adjusted based on MDCs: A set of claims may relate to three example
MDCs, "Injury One," "Injury Two," and "Injury Three." The average
paid loss for all claims for Injury One may be $5,000; the average
paid loss for all claims for Injury Two may be $10,000; and the
average paid loss for all claims for Injury Three may be $20,000.
According to this example, the average paid loss is two times
greater for Injury Three than for Injury Two, and four times
greater for Injury Three than for Injury One. Therefore, all paid
loss values for claims that are associated with Injury One may be
adjusted by being multiplied by a scaling factor of four, and all
paid loss values for claims that are associated with Injury Two may
be adjusted by being multiplied by a scaling factor of two. By
multiplying these paid loss values with these scaling factors, the
average paid loss across all three of the MDCs will be the same and
paid loss values across the different DMCs may be compared on a
normalized scale.
[0038] To adjust metric values based on the ages of claimants
handled by a service provider (step 210), the following approach
may be employed. Claims may be grouped according to the age of the
claimants. Then, for each group, an average metric value for claims
associated with the age may be determined. Then, a function may be
derived from the averages. The function may take a claimant age
range as an input, and generate a corresponding average metric
value (such as, for example, an average number of disability days)
as an output. Metric values may then be compared against values
generated by the function, and be adjusted based on the difference
between the metric values and the corresponding values generated by
the function.
[0039] Referring now to both FIG. 2 and FIG. 3, FIG. 3 shows an
example graph 300 that shows an example function 308 that may be
used to adjust metric values based on the ages of claimants handled
by a service provider (step 210). The graph 300 includes an X axis
302, which corresponds to claimant ages, and a Y axis 304, which
corresponds to an average number of disability days. The graph 300
also includes a curve 306, which is a graphical representation of
the function 308. The curve 306, as shown in FIG. 3, shows
correspondences between claimant age ranges (on the X axis 302) and
average disability days (on the Y axis 304).
[0040] Referring again to FIG. 2, to adjust metric values based on
the ages of claims handled by a service provider (step 210), the
following approach may be employed. Claims may be grouped according
to the age (in months, or some other unit of time) of the claim.
Then, for each group, an average metric value for claims associated
with the age. Then, a function may be derived from the averages.
The function may take a claim age as an input, and generate a
corresponding average metric value (such as, for example, an
average disability days) as an output. Metric values may then be
compared against values generated by the function, and be adjusted
based on the difference between the metric values and the
corresponding values generated by the function.
[0041] Referring now to both FIG. 2 and FIG. 4, FIG. 4 shows an
example graph 400 that shows an example function 408 that may be
used to adjust metric values based on the ages of claims handled by
a service provider (step 210). The graph 400 includes an X axis
402, which corresponds to claim age ranges, and a Y axis 404, which
corresponds to an average number of disability days. The graph 400
also includes a curve 406, which is a graphical representation of
the function 408. The curve 406, as shown in FIG. 4, shows
correspondences between claim age ranges (on the X axis 402) and
average disability days (on the Y axis 404).
[0042] Referring again to FIG. 2, after the metric values are
adjusted (step 210), the adjusted metric values may be compared,
and scores may be assigned to service providers based on the
comparisons (step 212). Here, adjusted metric values for each
metric may be sorted into ascending or descending order, and
percentage range distributions for the sorted values may be
determined.
[0043] The following table (Table 1) shows examples of percentage
range distributions for a number of example metrics:
TABLE-US-00001 TABLE 1 Top 10% Top 25% Top 50% Top 75% Top 90%
Average 7 5 3 2 1 claimant satisfaction Average 14 30 55 90 115
disability days Average $2,000 $5,000 $15,000 $30,000 $40,000 paid
loss
[0044] In the example of Table 1, the metrics that are used are
average claimant satisfaction, average disability days, and average
paid loss. For average claimant satisfaction, values may be defined
according to a scale of zero to ten, wherein zero represents the
lowest level of satisfaction and ten represents the highest level
of satisfaction. Table 1 is organized such that percentage ranges
for qualitatively better values are on the left size of the table
(e.g., a higher claimant satisfaction value is considered better
than a lower claimant satisfaction value), while percentage ranges
for qualitatively lesser values are on the right side of the
table.
[0045] Table 1 shows border values for the different percentage
ranges for each of the average claimant satisfaction, average
disability days, and average paid loss metrics. According to the
example of Table 1, the top 10% of claimant satisfaction values
were at seven or above; the next 15% of claimant satisfaction
values were from five to six; the next 25% of values were from
three to four; the next 25% of values were from one to two; and the
next 15% of values were one. Similarly, the top 10% of values for
the average number of disability days were less than fourteen; in
the next percentage ranges for this metric, the average numbers of
disability days were less than 30, 55, 90, and 155, respectively.
Further, the top 10% of values for average paid loss were less than
$2,000; in the next percentage ranges for this metric, the values
for average paid loss were less than $5,000, $15,000, $30,000, and
$40,000, respectively. After percentage range distributions are
determined, each service provider may be assigned a score for each
metric, based on which percentage range the service provider falls
within for that metric. The following table (Table 2) shows example
values that may be assigned based on percentage distributions:
TABLE-US-00002 TABLE 2 Percentage Range for Value to be Metric
Assigned Top 90%-100% 5 75%-90% 4 50%-75% 3 25%-50% 2 10%-25% 1
0%-10% 0
[0046] As a further example that uses the examples of Table 1 and
Table 2, a service provider may have the following values: an
average claimant satisfaction value of seven; an average disability
days value of fifty; and an average paid loss value of $35,000. For
average claimant satisfaction, this service provider would fall
within the top 90%-100% range, and so would be assigned a value of
five; for average disability days, this service provider would fall
within the 50%-75% range, and so would be assigned a value of
three; and for average paid loss, this service provider would fall
within the 10%-25% range, and so would be assigned a value of two.
In summary, the service provider would be assigned the following
scores: {5, 3, 1}.
[0047] As shown in the above example, favorable percentage ranges
correspond to higher values (e.g., the top 90%-100% range is
associated with a value of five, the 75%-90% range is associated
with a value of four, and so on.) In a variation on the above
example, favorable percentage ranges may correspond to lower values
and less favorable percentage ranges may correspond to higher
values. According to this variation, the top 90%-100% range may
correspond to a value of zero, the 75%-90% range may correspond to
a value of one, the 50%-75% range may correspond to a value of
three, and so on.
[0048] Final scores for each service provider may then be
determined by averaging the metric scores assigned to each service
provider (step 214). Referring again to the above example, the
service provider was assigned the following scores: {5, 3, 1}.
Averaging these scores would result in a final score for the
service provider of three. Alternatively or additionally, the final
scores may be a weighted average.
[0049] Then, the composition of the service provider network may be
determined based on the final service provider scores (step 216).
This may include, for example, determining that service providers
with a final score below a threshold are not included in the
service provider network, and that service providers with a final
score above the threshold are included in the service provider
network. As one example, a value of three may be used for the
threshold; according to this example, service providers with a
final score of three or above may be included in the service
provider network, while those with a final score of one or two are
not included in the service provider network. Alternatively or
additionally, service providers within a certain range of scores
may be classified differently from service providers within other
ranges. For example, service providers with a final score above a
threshold value may be considered to be "preferred" providers
within the network, while providers with final scores below the
threshold may be considered part of the network, but may not be
designated with a preferred status. In a variation on the above,
lower final scores may be considered better than higher local
scores; in such an instance, determining the composition of the
service provider network may include, as an example, determining
that service providers with a final score above a threshold are not
included in the service provider network and that service providers
with a final score below the threshold are included in the service
provider network.
[0050] Once the composition of the service provider network is
determined, the composition and/or other related information may
then be output (step 218). This may include, for example, storing
the results in one or more computer-readable media, displaying the
results on a display device, printing the results via a printer,
and/or communicating the results via a network interface. The other
related information that may also be output may include any of the
data or other parameter described above as used during steps 202
through 216, and/or other parameters.
[0051] Referring now to both FIG. 2 and FIG. 5, FIG. 5 shows an
example user interface element 500 that may be used to display data
that describes the composition of an example service provider
network on a display device (step 218). The example user interface
element 500 includes a header row area 502, a first row area 504, a
second row area 506, and a third row area 508.
[0052] The user interface element 500 of FIG. 5 shows service
provider network composition data that relates to three example
service providers, Provider One, Provider Two, and Provider Three.
The first row area 504 shows data that relates to Provider One;
Provider One has an average claimant satisfaction score of one, an
average disability days score of zero, and an average paid loss
score of three. These scores may be determined using the example
parameters described above with reference to Table 1 and Table 2.
These scores, when averaged, result in the final score of one, as
shown in the first row area 504. The second row area 506 and the
third row area 508 show corresponding data for Provider Two and
Provider Three, respectively. In this example, a threshold final
value of three may have been used to determine whether a service
provider should be included in the service provider network or not.
According to this example, and as shown in the row areas 502, 504,
506 in the user interface element 500, Provider One and Provider
Three are included in the service provider network, while Provider
Two is not included in the service provider network.
[0053] Referring to both FIG. 1 and FIG. 2, the method 200 of FIG.
2 may be performed using the example architecture 100 of FIG. 1, or
any other appropriate architecture. For example, the network
determining module 110 of FIG. 1 may perform the method 200 of FIG.
2. Alternatively or additionally, the input module 112 of FIG. 1
may perform step 202 of the method 200 of FIG. 2, the network
composition module 114 of FIG. 1 may perform steps 204 through 216
of the method 200 of FIG. 2, and the output module 116 of FIG. 1
may perform step 218 of the method 200 of FIG. 2.
[0054] FIG. 6 shows an example system 600 that may be used to
implement the example architecture 100 of FIG. 1, the method 200 of
FIG. 2, and/or to display the user interface element 500 of FIG. 5.
The example system 600 may include a data input computer 610, a
network determining computer 630, a provider search server 650, a
search client device 670, and one or more communication networks
690.
[0055] The data input device 610 may include a processor 618,
memory device 620, communication interface 622, input device
interface 612, display device interface 614, and storage device
616. The network determining device 630 may include a processor
638, memory device 640, communication interface 642, input device
interface 632, display device interface 634, and storage device
636. The provider search server 650 may include a processor 658,
memory device 660, communication interface 662, input device
interface 652, display device interface 654, and storage device
656. The search client device 670 may include a processor 678,
memory device 680, communication interface 682, input device
interface 672, display device interface 674, and storage device
676.
[0056] The data input device 610 may be configured to perform any
feature or combination of features described above with reference
to FIGS. 1-5 as performed by the data input module 124. The network
determining device 630 may be configured to perform any feature or
combination of features described above with reference to FIGS. 1-5
as performed by the claim information database module 120 and/or
the network determining module 110. The provider search server 650
may be configured to perform any feature or combination of features
described above with reference to FIGS. 1-5 as performed by the
service provider search module 130. The search client device 670
may be configured to perform any feature or combination of features
described above with reference to FIGS. 1-5 as performed by the
search client module 134. The search client device 670 may be, for
example, a desktop computer, a laptop computer, a netbook, a tablet
computer, a personal digital assistant (PDA), a cellular phone, or
any other appropriate device.
[0057] Each or any of the memory devices 620, 640, 660, 680 may be
or include a device such as a Dynamic Random Access Memory (D-RAM),
Static RAM (S-RAM), or other RAM or a flash memory. Each or any of
the storage devices 616, 636, 656, 676 may be or include a hard
disk, a magneto-optical medium, an optical medium such as a CD-ROM,
a digital versatile disk (DVDs), or Blu-Ray disc (BD), or other
type of device for electronic data storage.
[0058] Each or any of the communication interfaces 622, 642, 662,
682 may be, for example, a communications port, a wired
transceiver, a wireless transceiver, and/or a network card. Each or
any of the communication interfaces 622, 642, 662, 682 may be
capable of communicating using technologies such as Ethernet, fiber
optics, microwave, xDSL (Digital Subscriber Line), Wireless Local
Area Network (WLAN) technology, wireless cellular technology,
and/or any other appropriate technology. The communication
interfaces 622, 642, 662, 682 may be used by the data input device
610, the network determining device 630, the provider search server
650, and the search client device 670 to communicate via the one or
more communication networks 690. The one or more communication
networks 690 may include one or more private Local Area Networks
(LANs), and/or one or more public communication networks such as
the Internet. The one or more communication networks 690 may be
based on wired and/or wireless networking technologies.
[0059] Each or any of the input device interfaces 612, 622, 652,
672 may an interface configured to receive input from an input
device such as a keyboard, a mouse, a trackball, a scanner, a touch
screen, a touch pad, a stylus pad, and/or other device. Each or any
of the input device interfaces 612, 622, 652, 672 may operate using
a technology such as Universal Serial Bus (USB), PS/2, BLUETOOTH,
infrared, and/or other appropriate technology.
[0060] Each or any of the display device interfaces 614, 634, 654,
674 may be an interface configured to communicate data to a display
device. Each or any of the display device interfaces 614, 634, 654,
674 may operate using technology such as Video Graphics Array
(VGA), Super VGA (S-VGA), Digital Visual Interface (DVI),
High-Definition Multimedia Interface (HDMI), or other appropriate
technology.
[0061] The memory 620 and/or the storage device 616 of the data
input device 610 may store instructions which, when executed by the
processor 618, cause the processor 618 to perform any feature or
combination of features described above with reference to FIGS. 1-5
as performed by the data input module 124. The memory 640 and/or
the storage device 636 of the network determining device 630 may
store instructions which, when executed by the processor 638, cause
the processor 638 to perform any feature or combination of features
described above with reference to FIGS. 1-5 as performed by the
claim information database module 120 and/or the network
determining module 110. The memory 660 and/or the storage device
656 in the provider search server 650 may store instructions which,
when executed by the processor 658, cause the processor 658 to
perform any feature or combination of features described above with
reference to FIGS. 1-5 as performed by the provider search server
650. The memory device 680 and/or the storage device 676 in the
search client device 670 may store instructions which, when
executed by the processor 678, cause the processor 678 to perform
any feature or combination of features described above with
reference to FIGS. 1-5 as performed by the search client module
134.
[0062] Although examples are described above in terms of workers'
compensation and medical service providers, the principles
described above may be applied to any other appropriate context.
For example, the principles described above may be applied, mutatis
mutandis, to automobile insurance, property insurance, general
liability insurance, and/or any other insurance-related or
non-insurance-related context.
[0063] When referred to herein, the term "display device" broadly
refers to and is not limited to a monitor or television display, a
plasma display, a liquid crystal display (LCD), and/or a display
based on a technology such as front or rear projection, light
emitting diodes (LEDs), organic light-emitting diodes (OLEDs), or
Digital Light Processing (DLP).
[0064] When referred to herein, the term "computer-readable storage
medium" broadly refers to and is not limited to a register, a cache
memory, a ROM, a semiconductor memory device (such as a D-RAM,
S-RAM, or other RAM), a magnetic medium such as a flash memory, a
hard disk, a magneto-optical medium, an optical medium such as a
CD-ROM, a DVD, or BD, or other device for electronic data
storage.
[0065] As used herein, the term "processor" broadly refers to and
is not limited to a single- or multi-core general purpose
processor, a special purpose processor, a conventional processor, a
digital signal processor (DSP), a plurality of microprocessors, one
or more microprocessors in association with a DSP core, a
controller, a microcontroller, one or more Application Specific
Integrated Circuits (ASICs), one or more Field Programmable Gate
Array (FPGA) circuits, any other type of integrated circuit (IC), a
system-on-a-chip (SOC), and/or a state machine.
[0066] Although features and elements are described above in
particular combinations, each feature or element can be used alone
or in any combination with the other features and elements. For
example, each feature or element described above with reference to
any one or any combination of FIGS. 1-6 may be used alone without
the other features and elements or in various combinations with or
without other features and elements described above with reference
to any one or any combination of FIGS. 1-6. Sub-elements of the
methods and features described above may be performed in any
arbitrary order (including concurrently), in any combination or
sub-combination.
* * * * *