Patent ID: 7870009
Filing Date: 2011-01-11
Classification: G06Q,G16H

Abstract:
1. One or more computer readable storage media having computer-executable instructions stored thereon that executes a method in a computing environment for adjudicating and reimbursing a care provider for services provided for a clinical event, comprising: referencing an integrated transaction including a number of clinical data elements, wherein the clinical data elements comprise clinical event details electronically documented by the care provider at a point of care for the clinical event for which reimbursement is sought and electronic medical record data elements associated with a patient from an electronic medical record data store of a central computing system having historical electronic medical record data elements received from a plurality of sources; accessing a data store including payer information; determining whether at least a portion of medical care described in the integrated transaction is eligible for reimbursement by at least one payer by comparing the clinical data elements to plan information; accessing a first knowledge base comprising evidence-based criteria for providing medically appropriate care, wherein the evidence-based criteria comprises one or more guidelines and standards; selectively performing analysis of the clinical data elements of the integrated transaction against at least one evidence based criterion from the first knowledge base to determine if the care provided is medically appropriate; accessing a second knowledge base comprising at least one quality criterion for assessing quality of health care, wherein the at least one quality criterion comprises a mortality, a morbidity, a length of visit or stay in a healthcare facility, an onset of another condition due to poor care, a recurrence, an elimination of a presenting problem, a quality of life indicator, a patient satisfaction, and an unplanned visit due to poor care; selectively performing analysis of the clinical data elements of the integrated transaction against the at least one quality criterion to determine the quality of health care; and determining a level of reimbursement for a patient based on the determined medical appropriateness and the determined quality of the health care provided to the patient and authorizing reimbursement of the care provider from the at least one payer.