| 摘要 |
Systems, methods and computer-readable media are disclosed for performing various filtering operations and selection processing on healthcare claim transaction data associated with a plurality of healthcare claim transactions. The filtering operations may include a first filtering operation to identify healthcare claim transactions reimbursed at a loss and a second filtering operation to further identify those transactions reimbursed at a MAC rate below cost. The selection processing may be performed to identify, from among the filtered healthcare claim transactions and based at least in part on one or more selection parameter thresholds, those transactions that are suitable candidates for MAC rate appropriateness review by a claims processor. Upon identification of the candidate healthcare claim transactions, one or more representative claim transactions may be selected therefrom, and information associated therewith may be communicated to an appropriate claims processor as part of a request for an increase in MAC rate(s) associated with healthcare product(s). |
| 主权项 |
1. A method, comprising:
receiving, from one or more data sources, by a reimbursement analysis system comprising one or more computers, healthcare claim transaction data associated with a plurality of healthcare claim transactions; performing, by the reimbursement analysis system, a first filtering operation on the healthcare claim transaction data to identify a first group of healthcare claim transactions from among the plurality of healthcare claim transactions, wherein each healthcare claim transaction in the first group of healthcare claim transactions is associated with a respective healthcare product reimbursed at a respective reimbursement level that is below a cost associated with the respective healthcare product; performing, by the reimbursement analysis system, a second filtering operation to identify a second group of healthcare claim transactions from the first group of healthcare claim transactions; identifying, by the reimbursement analysis system and based at least in part on one or more selection parameter thresholds, a third group of candidate healthcare claim transactions from the second group of healthcare claim transactions; identifying, by the reimbursement analysis system, at least one healthcare claim transaction from the third group of healthcare claim transactions; and communicating, by the reimbursement analysis system, information associated with the at least one healthcare claim transaction to a claims processor system. |
