Optuminsight, Inc.

Ingenix, Inc.

Thomas E Lynn

Thinzar Mra Nyun

Kimberly Sanborn

Lynn Anne Richards

Derek C Pederson

Various embodiments for estimating a cost of a medical procedure. In one example, a method may include the operations of averaging data from various geographies of the amount billed to form a national average amount billed for the medical procedure; associating the average amount billed with one or more claim data items from a health plan; grouping the claim data items from the health plan using episode classes; calculating an average amount billed for each episode class; and adjusting the average amount billed for each episode class by a geographic adjustment factor to form an estimated cost of the medical procedure.

System, method and computer program for estimating medical costs

A system and computer-implemented method for grouping medical records implements a multi-level analysis of the records. The level of analysis is based upon the time proximity of each record to the defining medical procedure or service (anchor procedure) to be analyzed. Claim records are processed to determine whether any of the records should be grouped with the anchor procedure into a procedure episode group (PEG) using the date of service for each claim record and a level of relationship between the claim records and the anchor procedure. The requisite level of relationship between the claim records and the anchor procedure depends upon the position of the records within the time window. Claim records having the requisite relationship level associated with the portion of the time window in which they fall are included in the PEG.

System and method for grouping claim records associated with a procedure

A system and computer-implemented method for grouping medical records implements a multi-level analysis of the records. The level of analysis for each record is determined based upon the time proximity of each record to the defining medical procedure or service (anchor procedure) to be analyzed. Once an anchor procedure is identified, claim records are processed to determine whether any of the records should be grouped with the anchor procedure into a procedure episode group (PEG). First, the date of service for each claim record is identified to determine whether the claim record falls within time window. The claim records falling within the window then are assessed to determine whether each claim record is sufficiently related to the anchor procedure (for example, by determining whether the diagnostic, procedure, or episode treatment group coding of each claim record is associated with the anchor procedure). The requisite level of relationship between the claim records and the anchor procedure depends upon the position of the records within the time window. Only those claim records having the requisite relationship level associated with the portion of the time window in which they fall are included in the PEG.

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Chanhassen, MN, United States of America

Thomas E Lynn