COMPUTERIZED SYSTEM AND METHOD FOR CODING MEDICAL RECORDS TO FACILITATE PROVIDER REIMBURSEMENTS

摘要

A computerized system and method that allows healthcare providers to update the medical codes in health benefits provider member records. Healthcare providers access and update “suspect conditions” for member records in the database. The health benefits provider receives claims for services provided to its members as well as associated, supporting medical records and documentation for the claims. When processing claims, the health benefits provider enters and tracks the claim and related medical data in a database and identifies one or more “suspect conditions” by coding the member records with standardized medical codes such as HCC codes. The healthcare provider researches “suspect conditions” by reviewing supporting documentation and data and updates the records by affirming or denying conditions. The affirmed condition data for a member population along with revised encounter submissions may further be used in projecting risk scores to the member population and a level of reimbursement for the healthcare provider.

主权项

1. A computerized method for coding medical records comprising:
(a) receiving at a computer at least one healthcare claim for a member of a health benefits plan; (b) processing said at least one healthcare claim to identify a plurality of suspect medical conditions for said member; (c) adding to a member record for said member at least one medical code for each of said suspect medical conditions identified for said member; (d) storing in a suspect medical conditions database said member record with said medical codes; (e) receiving at said computer from a healthcare provider computer user a request to access said member record; (f) retrieving by said computer from said suspect medical conditions database said member record; (g) generating by said computer a display comprising:
(1) identifying data for said member;(2) a list of said medical codes for said suspect medical conditions; and(3) for each medical code in said list, an affirm option comprising a hyperlink to an affirm condition screen and a deny option; (h) receiving at said computer from said healthcare provider computer user a request to change an unconfirmed condition status of said medical codes in said list:
(1) by selecting said affirm option to confirm said suspect medical condition at said affirm condition screen; or(2) by selecting said deny option to deny said suspect medical condition; and (i) updating by said computer said member record to indicate said healthcare provider confirmation or denial of said medical codes for said suspect medical conditions according to said healthcare provider computer user selection of said affirm option or deny option.