Methods are provided for collecting fees for managing and optimizing the profitability of a plurality of physicians in a healthcare practice participating in an insurance network. The methods include establishing a relationship between a healthcare consultation group and the healthcare practice participating in the insurance network to increase the physician's profitability by reducing a risk of not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance network. The methods also include distributing predetermined percentages of savings attributed to the physicians' modified ancillary medical cost management behavior.
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8. A method of collecting fees for managing a plurality of physicians in a healthcare practice participating in an insurance network, the method comprising the steps of:
establishing a relationship between a healthcare consultation group and the a healthcare practice participating in the an insurance network to reduce a risk of the healthcare practice not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance network;
funding an incentive pool;
establishing a plan to pay funds from the funded incentive pool to the healthcare practice participating in the insurance network, wherein the payment of funds occurs in the plan when the ancillary medical costs of the a plurality of physicians in the healthcare practice do not decrease to a preselected level over a preselected period of time;
gathering, by a computer, data in a tangible computer medium from on each of the plurality of physicians in the healthcare practice participating in the insurance network including ancillary medical costs respective to the physicians;
modifying behavior of at least one of the plurality of physicians in the healthcare practice for management of the ancillary medical costs responsive to the gathered data gathered in the tangible computer medium;
determining, by the computer, whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the preselected level within the preselected period of time; and
distributing predetermined percentages of savings attributed to the modifying modified ancillary medical cost management behavior of the plurality of physicians if the ancillary medical costs have decreased to the preselected level over the preselected period of time.
1. A method of collecting fees for managing and optimizing the profitability of a plurality of physicians in a healthcare practice participating in an insurance network, the method comprising the steps of:
establishing a relationship between a healthcare consultation group and the a healthcare practice participating in the an insurance network to increase the profitability of a plurality of physicians' profitability physicians in the healthcare practice by reducing a risk of the healthcare practice not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance network;
funding an incentive pool;
gathering, by a computer, data in a tangible computer medium from on each of the plurality of physicians in the healthcare practice participating in the insurance network including ancillary medical costs respective to the physicians;
modifying behavior of at least one of the plurality of physicians in the healthcare practice for management of the ancillary medical costs responsive to the gathered data gathered in the tangible computer medium;
determining, by the computer, whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached a predetermined level within over a preselected period of time;
paying funds from the 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 the preselected level over the preselected period of time; and
distributing predetermined percentages of savings attributed to the modifying modified ancillary medical cost management behavior of the plurality of physicians ancillary medical cost management if when the ancillary medical costs of the plurality of physicians in the healthcare practice have decreased to the preselected level over the preselected period of time.
13. A method of collecting fees for managing and optimizing the profitability of an insurance network having a plurality of physicians in a healthcare practice participating therein, the method comprising the steps of:
establishing a relationship between a healthcare management consultation group and the a healthcare practice participating in the an insurance network to increase the insurance network's profitability by limiting the plurality of physicians' modifying ancillary medical cost management behavior of a plurality of physicians in the healthcare practice that is not preferred by the insurance network;
gathering, by a computer, data in a tangible computer medium from on each of the plurality of physicians in the healthcare practice participating in the insurance network regarding management of ancillary medical costs respective to the physicians;
modifying behavior of at least one of the plurality of physicians in the healthcare practice for management of the ancillary medical costs responsive to the gathered data gathered in the tangible computer medium;
determining, by the computer, whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached a preselected level within over a preselected period of time;
funding an incentive pool to be paid to the insurance network when the modified medical management practices do not decrease ancillary medical costs of the insurance network related to the ancillary medical costs of the plurality of physicians in the healthcare practice participating in the insurance network to the preselected level over the preselected period of time; and
distributing predetermined percentages of savings attributed to the modifying modified ancillary medical cost management behavior of the plurality of physicians ancillary medical cost management to at least one of to one or more of the following: the insurance network and the healthcare management consultation group, when the ancillary medical costs have decreased to the preselected level over the preselected period of time.
0. 21. A computer-assisted method of collecting fees for managing 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;
establishing an electronic communications network between a healthcare management consultation group and the healthcare practice participating in the insurance network to thereby facilitate communications between the healthcare management consultation group and the healthcare practice;
funding an incentive pool to provide for payment of funds under certain conditions;
establishing a plan to pay funds from the funded incentive pool to the healthcare practice participating in the insurance network, whereby the payment of funds occurs in the plan when the ancillary medical costs of the plurality of physicians in the healthcare practice do not decrease to a preselected level over a preselected period of time;
receiving data by the first computer for each of 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 plurality of physicians in the healthcare practice 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 plurality of physicians in the healthcare practice have reached the preselected level over the preselected period of time;
calculating a predetermined percentage of savings attributed to modified ancillary medical cost management behavior of the plurality of physicians; and
distributing the predetermined percentage of savings when the ancillary medical costs have decreased to the preselected level over the preselected period of time.
0. 20. A computer-assisted method of collecting fees for managing and enhancing profitability 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;
establishing an electronic communications network between a healthcare management consultation group and the healthcare practice participating in the 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 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 plurality of physicians by 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 the behavior 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 plurality of physicians in the healthcare practice have reached a predetermined level over a preselected period of time;
funding an incentive pool by the healthcare consultation group to provide for paying funds 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 the predetermined level over the preselected period of time;
performing the step of paying funds from the 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 the predetermined level over the preselected period of time;
calculating a predetermined percentage of savings attributed to modified ancillary medical cost management behavior of the plurality of physicians with respect to ancillary medical costs; and
distributing the predetermined percentage of savings to the healthcare practice participating in the insurance network when the ancillary medical costs of the plurality of physicians in the healthcare practice have decreased to the predetermined level over the preselected period of time.
0. 23. A computer-assisted method of collecting fees for managing and enhancing profitability 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;
establishing an electronic communications network between a healthcare management consultation group and the healthcare practice participating in the insurance network;
responsive to establishment of the electronic communications network between the healthcare management consultation group and the healthcare practice, 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,
responsive to the received data, 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 plurality of physicians by reducing a risk of the healthcare practice not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance network;
responsive to identifying 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, generating information by the first computer identifying recommended alternative ancillary medical procedures to modify the behavior 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 plurality of physicians in the healthcare practice have reached a predetermined level over a preselected period of time;
responsive to a result of the determination of whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the predetermined level over the preselected period of time, performing 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 the predetermined level over the preselected period of time; and
responsive to the result of the determination of whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the predetermined level over the preselected period of time, calculating a predetermined percentage of savings attributed to modified ancillary medical cost management behavior of the plurality of physicians with respect to ancillary medical costs; and
distributing the predetermined percentage of savings to the healthcare practice participating in the insurance network when the ancillary medical costs of the plurality of physicians in the healthcare practice have decreased to the predetermined level over the preselected period of time.
0. 26. A healthcare management system for collecting fees for managing and enhancing profitability of a plurality of physicians in a healthcare practice participating in an insurance network, the system comprising:
a computer to facilitate management of a healthcare practice participating in an insurance network, the computer having a tangible storage medium for storing computer executable program code; and
computer executable program code to facilitate modifying ancillary medical cost management behavior of a plurality of physicians in the healthcare practice and to facilitate paying a percentage of savings attributed to modified ancillary medical cost management behavior of the plurality of physicians, the computer executable program code stored in the storage medium of the computer and executable by the computer to perform the following operations:
establishing communications between the healthcare management consultation group and the healthcare practice participating in the insurance network,
responsive to establishment of communications between the healthcare management consultation group and the healthcare practice participating in the insurance network, receiving data from at least one other computer associated with the plurality of physicians, the received data indicating the ancillary medical costs attributed to each of the plurality of physicians in the healthcare practice participating in the insurance network,
responsive to the received data, 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,
responsive to identifying 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, generating information identifying alternative recommended ancillary medical practices to modify the behavior 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 whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached a preselected level over a preselected period of time,
responsive to determining whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the predetermined level within the preselected period of time, calculating for distribution to one or more of the following: the insurance network and the healthcare management consultation group, a predetermined percentage of savings attributed to modified ancillary medical costs management behavior of the plurality of physicians, and
distributing the predetermined percentage of savings attributed to the modified ancillary medical cost management behavior of the plurality of physicians when the ancillary medical costs have decreased to the preselected level over the preselected period of time; and
a funded incentive pool funded by the healthcare consultation group and configured to provide for paying funds to the insurance network when the modified ancillary medical costs management behavior does not decrease ancillary medical costs of the insurance network to the preselected level over the preselected period of time.
0. 25. A healthcare management system for collecting fees for managing and enhancing profitability of a plurality of physicians in a healthcare practice participating in an insurance network, the system comprising:
a computer to facilitate management of a healthcare practice participating in an insurance network, the computer having a tangible storage medium for storing computer executable program code; and
computer executable program code to facilitate modifying ancillary medical cost management behavior of a plurality of physicians in the healthcare practice and to facilitate paying a percentage of savings attributed to modified ancillary medical cost management behavior of the plurality of physicians, the computer executable program code stored in the storage medium of the computer and executable by the computer to perform the following operations:
establishing communications between a healthcare management consultation group and the healthcare practice participating in the insurance network to thereby facilitate a relationship between the healthcare management consultation group and the healthcare practice,
responsive to establishment of communications between the healthcare management consultation group and the healthcare practice participating in the insurance network, receiving data for each of the plurality of physicians in the healthcare practice participating in the insurance network, the received data including data indicating ancillary medical costs attributed to the plurality of physicians,
responsive to the received data, 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,
responsive to identifying 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, generating information identifying recommended alternative ancillary medical procedures to modify behavior of the plurality of physicians in the healthcare practice 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 whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the preselected level over the preselected period of time,
responsive to determining whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the predetermined level over the preselected period of time, calculating for distribution a predetermined percentage of savings attributed to modified ancillary medical cost management behavior of the plurality of physicians, and
distributing the predetermined percentage of savings attributed to the modified ancillary medical cost management behavior of the plurality of physicians when the ancillary medical costs have decreased to the preselected level over the preselected period of time; and
a funded incentive pool funded by the healthcare consultation group and configured to provide for paying funds 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 the predetermined level over the preselected period of time.
0. 24. A healthcare management system for collecting fees for managing and enhancing profitability of a plurality of physicians in a healthcare practice participating in an insurance network, the system comprising:
a computer to facilitate management of a healthcare practice participating in an insurance network, the computer having a tangible storage medium for storing computer executable program code; and
computer executable program code to facilitate modifying ancillary medical cost management behavior of a plurality of physicians in the healthcare practice and to facilitate paying a percentage of savings attributed to modified ancillary medical cost management behavior of the plurality of physicians, the computer executable program code stored in the storage medium of the computer and executable by the computer to perform the following operations:
establishing communications between the healthcare management consultation group and the healthcare practice participating in the insurance network,
responsive to establishment of communications between the healthcare management consultation group and the healthcare practice participating in the insurance network, 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 the plurality of physicians,
responsive to the received data, identifying 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 plurality of physicians by reducing a risk of the healthcare practice not receiving a predetermined reimbursement amount for ancillary medical costs from the insurance network,
responsive to identifying 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, generating information identifying recommended alternative ancillary medical procedures to modify the behavior of the plurality of physicians in the healthcare practice with respect to management of the ancillary medical costs,
determining whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached a predetermined level over a preselected period of time,
responsive to determining whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the predetermined level over the preselected period of time, calculating for distribution to the healthcare practice, a predetermined percentage of savings attributed to the modified ancillary medical cost management behavior of the plurality of physicians, and
distributing the predetermined percentage of savings attributed to the modified ancillary medical cost management behavior of the plurality of physicians when the ancillary medical costs of the plurality of physicians in the healthcare practice have decreased to the predetermined level over the preselected period of time; and
a funded incentive pool funded by the healthcare consultation group and configured to provide for paying funds 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 the predetermined level over the preselected period of time.
0. 22. A computer-assisted method of collecting fees for managing and enhancing profitability of an insurance network including 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;
establishing an electronic communications network between a healthcare management consultation group and the healthcare practice participating in the insurance network;
responsive to establishment of the electronic communications network between a healthcare management consultation group and the healthcare practice, 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 each of the plurality of physicians in the healthcare practice participating in the insurance network;
responsive to the received data, 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;
responsive to identifying 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, generating information identifying alternative recommended ancillary medical practices by the first computer to modify the behavior 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 plurality of physicians in the healthcare practice have reached a preselected level over a preselected period of time;
funding an incentive pool by the healthcare consultation group to provide for paying funds to the insurance network when the modified ancillary medical costs management behavior does not decrease ancillary medical costs of the insurance network to the preselected level over the preselected period of time;
responsive to the first computer determining whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the predetermined level over the preselected period of time, performing the step of paying funds from the funded incentive pool to the insurance network when the modified ancillary medical costs management behavior does not decrease ancillary medical costs of the insurance network to the preselected level over the preselected period of time;
responsive to the first computer determining whether the ancillary medical costs of the plurality of physicians in the healthcare practice have reached the predetermined level over the preselected period of time, calculating a predetermined percentage of savings attributed to modified ancillary medical costs management behavior of the plurality of physicians; and
distributing the predetermined percentage of savings to one or more of the following: the insurance network and the healthcare management consultation group, when the ancillary medical costs have decreased to the preselected level over the preselected period of time.
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The application is related to U.S. patent application Ser. No. 09/812,704, now U.S. Pat. No. 7,398,217, titled “Methods and Systems For Healthcare Practice Management” filed on the same date herewith by the same inventors, which is incorporated herein by reference in its entirety.
The present invention relates to the healthcare industry and, more particularly, to the field of healthcare management.
In the healthcare industry, as illustrated in
The step of modifying the physician's management behavior includes educating 70 the at least one physician 27 on benefits of alternative ancillary medical procedures. The education 70 of the physician 27 can be performed using research literature for comparing the alternative ancillary medical procedures to current ancillary medical procedures. The education 70 can further include organizing continued medical education classes 71 through ancillary medical facilities and can also include the education 72 of nurses and ancillary staff members. This is advantageous because continued medical education classes are generally required in order for a physician 27 to keep licensing requirements current. The continued medical education can advantageously fulfill the physician's licensing requirement while simultaneously educating the physician 27 as to the benefits of alternative ancillary medical procedures that may be more advantageous to themselves as well as to their patients.
The step of educating 70 the at least one physician advantageously includes providing the at least one physician national treatment guidelines for stepwise treatment of disease states. Too often prescription medication representatives, such as sales representatives, convince physicians 27 that the newest medication is necessary to treat patients 35 and other regimens should be skipped or abandoned. The step of educating 70 the physicians 27, therefore, includes recommending that physicians 27 follow nationally recognized guidelines and treatment protocols, such as from the Center for Disease Control (CDC) and the National Institute of Health (NIH), for example.
This advantageously ensures that community accepted standards of care are being provided. The step of educating 70 the physicians 27 also advantageously includes identifying the medications of choice for given disease states and verifying, through data analysis and dialog, that medical research indicates that modified physicians behavior will have a favorable impact. The step of educating 70 the physicians 27 using peer-reviewed, medical research based literature recommending nationally recognized guidelines also advantageously decreases liability incurred by physicians 27. The physicians' 27 medical malpractice liability can advantageously be decreased if the physician follows nationally recognized guidelines and treatment protocols.
The step of modifying the physician's management behavior also includes providing patient history updates. If, for example, the physician 27 makes a decision to modify a patient's 35 prescription medication in the interest of decreasing pharmacy cost, for example, the patient history updates become very advantageous for the general safety and welfare of the patient 27. At the time of ordering the new prescription, physicians 27 may not have all the patient's 35 medical history to prescribe a medication without inducing an adverse drug reaction (ADR). ADR's often lead to increased repeat visits to the physician 27 for the same ailment and possibly to a hospital, which increase the healthcare practice's 25 health care cost tremendously. After the gathered data, provided by a pharmacy benefits management (PBM) company or a pharmacy claims benefit administrator, for example, is analyzed, printouts of the patients' 35 prescription history can advantageously be provided to the physician 27. These printouts may be included in patient 35 charts for up-to-date reference by the physicians 27.
As best illustrated in
As also illustrated in
Physicians 27 sometimes participate in a number of insurance networks 30. Differing insurance networks 30 normally have differing preferred ancillary medical procedures. When the physicians 27 participate in differing insurance networks 30, it becomes difficult to determine which ancillary medical procedures are preferred by each of the different insurance networks 30. The various insurance networks 30 normally have overlapping ancillary medical procedures. Therefore, the step of providing custom ancillary medical procedure customization forms also includes the step of providing custom ancillary medical procedure forms that account for the overlapping ancillary medical procedures of the various networks and advantageously eliminate the need for the physician 27 to take the time to research what insurance network 30 the patient 35 participates in and which ancillary medical procedures are preferred by the particular insurance network 30 in which the patient 35 participates. The custom ancillary medical form that accounts for overlapping ancillary medical procedures between various insurance networks 30 advantageously allows the physician 27 to engage in any ancillary medical procedure that is listed on the form without any risk of not receiving the predetermined reimbursement amount from the insurance network 30.
As best illustrated in
The step of providing patient intervention can advantageously include contacting patients 35 that are affected by poly-pharmacy and non-compliance, for example. The step of contacting patients includes contacting the patients 35 on a monthly basis. Poly-pharmacy occurs when the patient 35 is taking medications with ADR's, unnecessary medications, or those from the same medication class. In addition, if it is discovered during the step of analyzing the gathered data that the patient 35 is not taking the prescription medication as required, the step further includes contacting the patient 35 with a directive to comply with the treatment protocols. The contact to the patient 35 can, for example, be made in the form of a letter written on the physician's 27 letterhead.
The step of providing patient intervention also advantageously includes determining if stronger disease state management techniques are required. This determination is conducted on a monthly basis. For those patients 35 with aggressive diseases, specialist organizations are employed to provide recommendations to the physicians 27 and the patients 35 on the latest treatments techniques.
The steps of discontinuing and amending current ancillary medical procedures include providing information to the patients 35 regarding the benefits of the new alternative medical procedure, e.g., information that a lay-patient can understand regarding the benefits of an alternative prescription medication. The step of providing patient intervention also includes providing a monthly review of patient's charts to determine if the new ancillary medical procedures are sufficient for the patient's treatment. As patients are identified 56 that are not being treated per guidelines of alternative ancillary medical procedures, a chart 48 is advantageously inserted into a patient's medical chart, recommending an alternative ancillary medical procedure. The chart insert 48 advantageously includes an explanation of the recommended and pre-written ancillary medical procedure orders, i.e., pre-written prescriptions, for the physician's approval.
The physicians 27, however, do not always yield to the preferred ancillary medical procedures of the insurance network 30. When the physicians 27 encounter a situation where, relying on their vast medical knowledge, they know a proposed ancillary medical procedure is detrimental to the patient 35, then the insurance network 30 is approached to consider modifying their preferred ancillary medical procedures. Like the physicians 27, the insurance network 30 is educated regarding the benefits of the ancillary medical procedure that they seek to modify. This advantageously levels the playing field between physicians 27 and insurance networks 30. The present invention provides for the possibility that the insurance network 30 will yield to the medical judgment of the physician 27 concerning the treatment of patients 35.
The step of discontinuing an ancillary medical procedure further includes the step of preparing a plurality of letters 86. The step of preparing letters includes the healthcare consultation group 22 obtaining permission 84 from the physician 27 to distribute letters 87 to the patients 35 that are candidates for modification of ancillary medical procedures. One of the plurality of letters informs the ancillary medical facility of the discontinuation of a particular ancillary medical procedure 88. Another of the plurality of letters informs the patient that a particular ancillary medical procedure is discontinued 87. The letters can advantageously be written on the physician's letterhead. The letter to be sent to the patient 35 advantageously includes a detailed explanation of why the ancillary medical procedure is being modified, the benefits of the new ancillary medical procedure, and the advantages that patient 35 will obtain from using the new ancillary medical procedures. The letter to be sent to the ancillary medical facility 88 instructs the ancillary medical facility that the ancillary medical procedure is discontinued and can also advantageously inform the ancillary medical facility of an amendment to the ancillary medical procedure. The step of discontinuing the ancillary medication also includes providing the physician 27 with a list of “frequently asked questions and answers” so that the physician 27 is prepared for what may be difficult questions posed by the patients 35. This advantageously allows the physician 27 to give the patients 35 clear and concise answers that do not make the patient 35 feel as though the physician 27 and the insurance network 30 are taking advantage of the patient.
The step of providing patient intervention also advantageously includes ordering a new alternative ancillary medical procedure upon a new diagnosis 83. The step of ordering a new ancillary medical procedure advantageously includes providing a monthly update 90 to the physicians 27 regarding new alternative ancillary medical procedures. The monthly updates can come in the form of a newsletter, for example. The step of ordering a new ancillary medical procedure also advantageously includes providing a review 91 between the physician 27 and the healthcare consultation group 25 regarding new ancillary medical procedures and education 92 provided to the physicians 27 and patients 35 regarding the new ancillary medical procedures. The patient's chart is periodically reviewed 93 to ensure that the new ancillary medical procedure is effective and treatment guidelines are provided 94 on a chart insert 48, as illustrated in
The methods of managing the healthcare practice 25 and optimizing the profitability of the insurance network 30 also advantageously include updating physicians 27 regarding changes of ancillary medical procedures preferred by the insurance network 30. The step of updating can advantageously include mailing the updated changes to each of the physicians 27 in the healtheare healthcare provider group 22 using a newsletter, or can advantageously include transmitting the changes to the physicians 27 via electronic mail or flyers, or other types of updates. The step of updating can also advantageously include connecting to a communications network 100 to access the updated information. This advantageously eliminates the time necessary for the physicians 27 to research new preferred ancillary medical procedures. The updates are also a form of continuing education for the physician 27 to learn of new techniques and medications that are available to enhance the treatment of the patients 35.
Some healthcare practices 25 have opted to use personal digital assistants (PDAs) or other electronic data entry and retrieval hardware in their practices. For those groups, whenever possible, the hardware and/or software will be integrated with the information and services provided as described above. Allscripts, Parkstone, and Realtime Rx are just a few examples of companies that sell or lease such equipment. This will be done in an effort to disencumber the physicians 27 so they can focus on better management of their time.
As best illustrated in
The system 20 of the present invention also includes an analyzer such as provided by software programs stored on a computer or processor, as understood by those skilled in the art, positioned on the server 102 and in communication with the first and second databases for comparing the ancillary medical procedures that are preferred by the insurance network 30 with the ancillary medical costs of the plurality of physicians 27 participating in the insurance network 30. The analyzer advantageously identifies ancillary medical costs of the physicians 27 that are not preferred by the insurance network 30. The analyzer further includes calculating means for calculating an average ancillary medical cost per physician 27 for the healthcare practice 25. The average ancillary medical cost is used to identify the physicians 27 that are in need of assistance to reduce the risk of not receiving the predetermined reimbursement amount for ancillary medical costs from the insurance network 30.
The system 20 still further includes recommending means, e.g., provided by software, as understood by those skilled in the art, positioned on the server 102 and responsive to the user interface, for recommending to each of the plurality of physicians 27 alternative ancillary medical procedures that are preferred by the insurance network 30. The recommending means can advantageously be provided by software that resides on the server 102. The system also preferably includes managing means, e.g., provided by software, as understood by those skilled in the art, for managing ancillary medical cost management behavior of the physicians 27. The managing means can advantageously be provided by software that resides on the server 102. The managing means preferably includes a modifier to modify the management behavior of the physicians 27 so that the physicians 27 engage in ancillary medical procedures that are preferred by the insurance network 30. The managing means also includes an identifier for identifying at least one of the plurality of physicians 27 in the healthcare practice 25 participating in the insurance network 30 that is at a greater risk of not receiving a predetermined reimbursement amount for the ancillary medical costs from the insurance network 30 because of engagement in ancillary medical procedures that are not as profitable to the insurance network 30.
The system 20 of the present invention still further includes patient intervening means, e.g., provided by software, as understood by those skilled in the art, for identifying at least one patient 35 whose present ancillary medical procedures are not preferred by the insurance network 30. The patient intervening means can advantageously be provided by software that resides on the server 102. The management means of the system 20 further includes generating means, e.g., also preferably provided by software, as understood by those skilled in the art, for generating a plurality of letters to modify the ancillary medical procedures of the physician 27. The letters include first and second letters. The first letter informs the ancillary medical facility that the patient's 35 present ancillary medical procedure is modified. The second letter is sent to the patient 35 to inform the patient of the new ancillary medical procedure. The second letter includes educational information informing the patient 35 of the benefits of the new ancillary medical procedure and educational materials that may answer any questions that the patient 27 may have.
As illustrated in
The method of collecting fees 120 can advantageously include the step of the healthcare consultation group 22 funding an incentive pool 124 to be paid to the healthcare practice 25, or to the insurance network 30, depending upon who hires the healthcare consultation group 22. The healthcare consultation group 22 only collects a fee if their services to the healthcare practice 25 and the insurance network 30 are successful. Therefore, the fees are only collected on a success-fee basis. In some cases, however, a nominal fee may be charged by the healthcare consultation group 22 before services are performed. The measure of success of the services of the healthcare consultation group 22 is a decrease in healthcare costs of the insurance network 30 and the physicians 27 in the healthcare practice 25 for specific ancillary medical costs. If services of the healthcare consultation group 22, however, do not decrease healthcare costs for the plurality of physicians 27 or the insurance network 30 below a predetermined level over a preselected period of time, the finds funds in the incentive pool are turned over to the healthcare practice 25 or the insurance network 30, depending on who is the healthcare consultation group's 22 client. This advantageously provides accountability to the healthcare consultation group 22. Accountability will ease the minds of the healthcare practice 25 and insurance network 30 giving the healthcare consultation group 22 a chance to prove that profits can be enhanced.
The method of collecting fees 120 further includes distributing predetermined percentages 126 of savings attributed to the services of the healthcare consultation group 22. As illustrated in
The step of distributing predetermined percentages 126 of savings attributed to the services of the healthcare consultation group 22 can advantageously vary depending on whether the client of the healthcare consultation group 22 is the healthcare practice 25 or the insurance network 30. The distributed percentages can advantageously be equal between the healthcare consultation group 22, the insurance network 30, and the healthcare practice 25. If, for example, the client of the healthcare consultation group 22 is the healthcare practice 25, then the predetermined percentages distributed to the healthcare consultation group 22 and the healthcare practice 25 can be greater than the predetermined percentage of the savings that are distributed to the insurance network 30, e.g., the insurance network 30 may not collect any percentage of the savings. If, however, the client of the healthcare consultation group 22 is the insurance network 30, then the predetermined percentages distributed to the healthcare consultation group 22 and the insurance network 30 can be greater than the predetermined percentage of the savings that are distributed to the healthcare practice 25.
The method of collecting fees can also advantageously include a pricing, billing, or charging structure. The pricing structure of the healthcare consultation group 22 is straight forward. The clients, i.e., the healthcare practice 25 or the insurance network 30, measure their ancillary medical costs, or pharmacy costs for example, on a per-member per-month (PMPM) basis. During a pharmacy assessment, an average PMPM pharmacy cost (baseline PMPM) is calculated using the clients past six months pharmacy claims and membership data. Each month, the current month's average PMPM pharmacy cost is subtracted from baseline PMPM in order to determine the savings realized from the healthcare consultation group's 22 services.
A commission fee can advantageously be calculated on predetermined percentage of the monthly client savings, e.g., 50% of monthly savings, multiplied by the number of patients each month. For example, a sustained $1.00 PMPM savings for a client with 30,000 covered lives would yield to the healthcare consultation group 22 $15,000 per month, for up the duration of the contract. The contract can span between one and three years, for example, or can have a longer duration. The healthcare consultation group 22 can collect a smaller fee percentage for longer contract durations. If the client desires a longer contract duration, the baseline PMPM can advantageously be increased yearly with respect to annual inflation increases of wholesale prescription medication costs. The risk reversal for the client is that if there is no savings any month, the client pays nothing.
The pricing structure can also advantageously include a referral commission, e.g., $0.25, for each covered life, or a percentage of the client's savings for example, provided to the strategic marketing partners. This referral commission compensates for the commissions paid to sales people and people who refer business to the healthcare consultation group 22. Thus, the healthcare consultation group 22 minimizes the marketing budget while advantageously maximizing marketing results.
The application is related to U.S. patent application Ser. No. 09/812,704, now U.S. Pat. No. 7,398,217, titled “Methods and Systems For Healthcare Practice Management” filed on the same date herewith by the same inventors, which is incorporated herein by reference in its entirety.
In the drawings and specification, there has been disclosed a typical preferred embodiment of the invention, and although specific terms are employed, the terms are used in a descriptive sense only and not for purposes of limitation. The invention has been described in considerable detail with specific reference to these illustrated embodiments. It will be apparent, however, that various modifications and changes can be made within the spirit and scope of the invention as described in the foregoing specification and as defined in the appended claims.
Lewis, Charles, Moore, Terrance
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