Abstract:
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.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application claims priority to U.S. Provisional Patent Application Ser. No. 61/599,674, filed Feb. 16, 2012 and titled COMPUTERIZED SYSTEM AND METHOD FOR CODING MEDICAL RECORDS TO FACILITATE PROVIDER REIMBURSEMENTS, the contents of which is incorporated herein by reference. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    To facilitate reimbursements to healthcare providers, organizations such as the Center for Medicare Services (CMS) and other health benefits payors require coding of medical records. Coding classifications, such as CMS&#39;s hierarchical condition categories (HCC), are used to identify numerous clinical diagnoses or medical conditions relevant to a patient&#39;s health. For example, one code identifies chronic pulmonary heart disease while another code identifies a diagnosis of diabetes. The patient record of an individual with multiple chronic health conditions may have multiple codes identifying each of the associated health conditions. For example, an individual who has arthritis may also have osteoporosis and high blood pressure. The patient&#39;s electronic record therefore, may have a first code for arthritis, a second code for osteoporosis, and a third code for high blood pressure. 
         [0003]    Codes may be identified for medical records by healthcare providers, health benefit providers, and other organizations that may be granted access to a patient&#39;s records. Although great care is taken in coding medical records properly, errors and omissions can occur. For example, a healthcare provider may fail to add a code to a patient&#39;s record for a newly diagnosed health condition or to provide the correct code for the specific form of a patient&#39;s health condition. For example, various codes for renal failure are used to identify specific forms of the disease. To facilitate reimbursement and for other reasons, it is important for medical records to be coded accurately. 
         [0004]    Because the information most relevant to an individual&#39;s health status typically originates at a healthcare provider that is typically reimbursed by a health benefits provider or other third party payor, medical records received by payors are initially coded according to data received from the healthcare provider. The coding details are typically obtained from the provider&#39;s claim or request for reimbursement data. Records are not always coded correctly and when coding errors are discovered, they are often discovered in connection with claims for reimbursement. Because the provider&#39;s reimbursement may depend upon proper medical record coding, it is important for providers to have the ability to correct or change codes when questions regarding the coding are raised or when errors are discovered. 
         [0005]    Although coding problems may be resolved in various ways such as through direct communications between the healthcare provider and health benefits provider or payor, this approach is neither the most efficient nor effective. The volume of claims generated by healthcare providers and received by health benefits providers is so great that resolving problems by telephone, email, or fax communications is impractical. Even if the individuals involved in the telephone, email, or fax communications reach agreement on the resolution of a coding problem, one or more associated electronic records must be updated. In many instances, it would be much more efficient for the healthcare providers to have access to records that need to be corrected and to allow them to correct them directly. 
         [0006]    There is a need for a computerized system and method that allows healthcare providers to access and modify medical record codes for member records of a health benefits provider. In particular, there is a need for a computerized system and method that allows healthcare providers to respond to “suspect conditions” identified in member records for a member population. There is a need for a computerized system and method that allows healthcare providers to enter and correct codes for medical records stored at a health benefits provider and used for reimbursement of services. 
       SUMMARY OF THE INVENTION 
       [0007]    The present disclosure is directed to a web-based tool that grants healthcare providers the ability to make real-time updates to the medical codes in health benefits provider member records. In an example embodiment, healthcare providers access and update “suspect conditions” in a health benefits provider&#39;s Suspect Tracking And Reporting (STAR) 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. In connection with processing claims for reimbursement, 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 is provided with access to the database records and permitted to update records while researching “suspect conditions” in supporting documentation and data. The healthcare provider may review written reports and other relevant data to affirm or deny the “suspected condition” identified in a member record. As a result, healthcare providers and the health benefits provider are assured that all data associated with a patient&#39;s medical record is as current and accurate as possible. The affirmed condition data for a member population along with revised encounter submissions may further be used in projecting risk scores to the population and a level of reimbursement for the healthcare provider. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0008]      FIG. 1  is a sample STARs application access page according to an example embodiment; 
           [0009]      FIGS. 2A and 2B  are sample member list pages according to an example embodiment; 
           [0010]      FIG. 3  is a sample “condition status details” page according to an example embodiment; 
           [0011]      FIGS. 4A-4C  are sample “affirm condition” pages according to an example embodiment; 
           [0012]      FIG. 5  is a sample “condition status details” page according to an example embodiment; 
           [0013]      FIGS. 6A and 6B  are sample “condition status detail” pages according to an example embodiment; 
           [0014]      FIG. 7  is a sample “no conditions” page according to an example embodiment; 
           [0015]      FIGS. 8A and 8B  are sample “add condition” pages according to an example embodiment; 
           [0016]      FIG. 9  is a sample “member condition” profile pages according to an example embodiment; 
           [0017]      FIGS. 10A-10D  are sample “provider affirm condition” pages according to an example embodiment; 
           [0018]      FIG. 11  is a sample activity report according to an example embodiment; 
           [0019]      FIG. 12  is a sample condition status report page according to an example embodiment; 
           [0020]      FIGS. 13A and 13B  are sample member listing report pages according to an example embodiment; 
           [0021]      FIG. 14  is a sample “member not updated” report page according to an example embodiment; and 
           [0022]      FIG. 15  is a sample “unresolved level one conditions” report page according to an example embodiment. 
       
    
    
     DETAILED DESCRIPTION 
       [0023]    Referring to  FIG. 1 , a sample STAR application access page according to an example embodiment is shown. The page comprises “provider”  100  and “member status”  102  options. The provider list identifies individual healthcare providers or healthcare facilities affiliated with the user&#39;s login identity. The user may select one or more providers from the list. The member status list comprises a plurality of member conditions. In an example embodiment, the status conditions are: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 Member Status Conditions 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Level One Open 
                 Conditions more likely to be seen in a provider 
               
               
                 Conditions 
                 office setting than a hospital setting. Example 
               
               
                   
                 “level one” Conditions are listed in Table 2. 
               
               
                 Open Conditions 
                 List of members having at least one open suspect 
               
               
                   
                 condition, regardless of whether the open 
               
               
                   
                 condition is a “level one” condition. All of a 
               
               
                   
                 member&#39;s conditions are displayed as long as 
               
               
                   
                 that member has at least one open condition. 
               
               
                 Affirmed 
                 List of members having at least one affirmed 
               
               
                 Conditions 
                 condition. All of a member&#39;s conditions are 
               
               
                   
                 displayed as long as that member has at least 
               
               
                   
                 one affirmed condition. 
               
               
                 “CMS accepted” 
                 List of members having at least one CMS accepted 
               
               
                 Conditions 
                 condition. All of a member&#39;s conditions are 
               
               
                   
                 displayed as long as that member has at least 
               
               
                   
                 one CMS accepted condition. 
               
               
                 Conditions 
                 List of members having at least one condition, 
               
               
                   
                 regardless of the status of that condition 
               
               
                   
                 (Open, Affirmed, “CMS accepted”, etc.). 
               
               
                 No Conditions 
                 List of members that do not have any conditions. 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
             
               
               
             
           
               
                 TABLE 2 
               
             
             
               
                   
               
               
                 Example “Level One” Conditions 
               
             
          
           
               
                 HCC 
                 DESCRIPTION 
               
               
                   
               
             
          
           
               
                 10 
                 BREAST, PROSTATE, COLORECTAL AND 
               
               
                   
                 OTHER CANCERS AND TUMORS 
               
               
                 15 
                 DIABETES WITH RENAL OR PERIPHERAL 
               
               
                   
                 CIRCULATORY MANIFESTATION 
               
               
                 16 
                 DIABETES WITH NEUROLOGIC OR OTHER 
               
               
                   
                 SPECIFIED MANIFESTATION 
               
               
                 18 
                 DIABETES WITH OPHTHALMOLOGIC OR 
               
               
                   
                 UNSPECIFIED MANIFESTATION 
               
               
                 19 
                 DIABETES WITHOUT COMPLICATION 
               
               
                 27 
                 CHRONIC HEPATITIS 
               
               
                 38 
                 RHEUMATOID ARTHRITIS AND INFLAMMATORY 
               
               
                   
                 CONNECTIVE TISSUE DISEASE 
               
               
                 68 
                 PARAPLEGIA 
               
               
                 71 
                 POLYNEUROPATHY 
               
               
                 73 
                 PARKINSON&#39;S AND HUNTINGTON&#39;S 
               
               
                   
                 DISEASES 
               
               
                 74 
                 SEIZURE DISORDERS AND CONVULSIONS 
               
               
                 80 
                 CONGESTIVE HEART FAILURE 
               
               
                 83 
                 ANGINA PECTORIS/OLD MYOCARDIAL 
               
               
                   
                 INFARCTION 
               
               
                 92 
                 SPECIFIED HEART ARRHYTHMIAS 
               
               
                 100 
                 HEMIPLEGIA/HEMIPARESIS 
               
               
                 105 
                 VASCULAR DISEASE 
               
               
                 108 
                 CHRONIC OBSTRUCTIVE PULMONARY 
               
               
                   
                 DISEASE 
               
               
                 130 
                 DIALYSIS STATUS 
               
               
                 131 
                 RENAL FAILURE 
               
               
                 132 
                 NEPHRITIS 
               
               
                 149 
                 CHRONIC ULCER OF SKIN, EXCEPT 
               
               
                   
                 DECUBITUS 
               
               
                 176 
                 ARTIFICIAL OPENINGS FOR FEEDING 
               
               
                   
                 OR ELIMINATION 
               
               
                 177 
                 AMPUTATION STATUS, LOWER LIMB 
               
               
                   
                 AMPUTATION COMPLICATIONS 
               
               
                   
               
             
          
         
       
     
         [0024]    Selection of the “level one open conditions” search criteria returns a list of members that have at least one open “level one” condition. In addition to displaying open “level one” conditions, the member condition profile also includes all “CMS accepted” conditions, along with all “level one” conditions regardless of suspect status. In an example embodiment, all of a member&#39;s conditions are not displayed in the “level one” search results. Only those conditions that are “level one” conditions or “CMS accepted” conditions appear in the member condition profile. 
         [0025]    Referring to  FIGS. 2A and 2B , a sample “member list” page according to an example embodiment is shown. Referring to  FIG. 2A , identifying data for members meeting the selection criteria is displayed in a window  120 . Referring to  FIG. 2B , the user may scroll through the list of member names by selecting a “previous” or “next” option  122 . 
         [0026]    Referring to  FIG. 3 , a sample “condition status details” page according to an example embodiment is shown. The user may view the condition status details for a specific member by initiating a “left click” option on the member&#39;s name  130 . The member&#39;s condition profile is displayed  132 , listing all conditions for that member according to the search member status option used to initiate the search. The member condition profile comprises the following details: member name; member identifier; member&#39;s date of birth; risk scores for three CMS periods; HCC; condition description; condition status for 2 nd  prior year CMS period; condition status for 1 st  prior year CMS period; and condition status for current CMS period. Once a member has been selected, the message at the bottom of the screen (“Last STAR update . . . ”)  134  identifies the last date that a condition has been added, affirmed, or denied in the STAR database for that member. If the member&#39;s prior period or current period conditions have not been updated in the STAR database, the message is “N/A” instead of a date. 
         [0027]    Based upon information contained in the medical record there are several possible actions the user can perform: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 3 
               
             
             
               
                   
               
               
                 User Options 
               
             
          
           
               
                 Action 
                 Description 
               
               
                   
               
               
                 Affirm or Deny 
                 HCC Code - 15 Diabetes With Renal 
               
               
                 136 
                 or Peripheral Circulatory Manifestation - 
               
               
                   
                 Affirm or Deny Condition (Year 115 
               
               
                   
                 and/or Year 125). 
               
               
                 Deny 
                 HCC Code - 19 Diabetes Without 
               
               
                 138 
                 Complication - Deny Condition (Year 115) 
               
               
                 Add New Condition 
                 Identify a new condition for the member 
               
               
                 140 
               
               
                 Print Conditions 
                 Print member&#39;s condition profile grid 
               
               
                 142 
               
               
                 Select New Member 
                 Select a new member from the member list 
               
               
                 144 
               
               
                 Search for a New 
                 Search for a different member by last name 
               
               
                 Member 146 
               
               
                 Create Reports 
                 Create several types of reports 
               
               
                 148 
               
               
                   
               
             
          
         
       
     
         [0028]    The details of the example medical record indicates that the member has HCC 15—Diabetes With Renal or Peripheral Circulatory Manifestation. To “affirm” this condition for year 115, the user left clicks on the “affirm” word link for HCC 115 in the CMS Date Range 115 column of the member&#39;s condition profile grid  136 . In response to the user action, an “affirm condition” page as shown in  FIG. 4A  is displayed. The page is populated with member details  160 . The user is further presented with an option to enter an appropriate ICD-9 code associated with the displayed condition  162 . The user may select from a list of ICD9 Codes in a drop down list  164  as illustrated in  FIG. 4B . The drop down list comprises all applicable ICD9 codes and their descriptions. ICD9 codes associated with the condition displayed on the “affirm condition” page appear in the ICD9 code drop down list. Referring to  FIG. 4C , the user may further enter an applicable date of service  166 . After reading the message box  168  (confirming that documentation for the condition is found in the member&#39;s medical record and acknowledging that an encounter must be submitted for the condition), the user may select the “confirm” option  170 . Selection of the “confirm” option updates the member&#39;s condition status and returns the user to the member condition profile page. If desired, the user can cancel the transaction by selecting the cancel option. When the cancel option is selected, the database is not updated and the member condition profile page is presented. 
         [0029]    Referring to  FIG. 5 , a sample “condition status details” page (following a user&#39;s affirmation of condition code 15) according to an example embodiment is shown. The page shows that in Year 115, Condition Code 15—Diabetes With Renal or Peripheral Circulatory Manifestation is a “provider affirmed condition”  180 . The database update message at the bottom of the screen  134  (“Last STAR update to this member was on: 03/31/2009”) is not updated even though a condition has been updated for this member. The message is not refreshed real-time. To see the updated message, the user exits the STAR session, then logs back into the STAR application. After initiating another STAR session, the user selects the appropriate search member status criteria to retrieve the updated member data. When the member is selected from the member list, the message at the bottom of the screen displays the current date at the last STAR database update date. 
         [0030]    Referring to  FIG. 6A , a sample “condition status details” page (prior to a user&#39;s denial of condition code 80) according to an example embodiment is shown. For a selected member  190 , a provider may deny a condition based on the absence of supporting documentation in the member&#39;s medical record. In the example, assuming the member&#39;s medical record contains no documentation to support the open condition “HCC 80—Congestive Heart Failure,” the user may deny this condition for Year 115 by selecting the “deny” word link  192  for HCC 80 in the CMS Date Range 115 column of the member&#39;s condition profile grid. As shown in  FIG. 6B , this action refreshes the member condition profile screen to indicate that in Year 115, Condition Code 80—Congestive Heart Failure is a “provider denied condition”  194 . 
         [0031]    Referring to  FIG. 7 , a sample “no conditions” page according to an example embodiment is shown. If, upon reviewing a member&#39;s medical record, the user discovers documentation supporting a condition not displayed for a member, the new condition may be added to the member&#39;s condition profile. Conditions may be added for members found in any of the search member status search options. The user selects the “add new condition” option  200  to add an applicable condition. 
         [0032]    Referring to  FIG. 8A , an “add condition” page according to an example embodiment is shown. The user may add a new condition for a selected member  210  based upon supporting documentation found in the member&#39;s medical record. To add a new HCC condition, the user selects from drop down lists a CMS date range  212 , a condition  214 , and a related ICD9 code  216 . The user further provides a date of service  218 . After reviewing the confirmation message, the user may select the confirm option  220  to add the new condition. Referring to  FIG. 8B , a sample “provider affirmed new condition” page according to an example embodiment is shown. In the update page, the new condition appears along with the “provider affirmed condition” indicator  222 . 
         [0033]    A user may also change a “provider affirmed condition” and “provider denied condition” if a condition that is displayed is incorrect based on either documentation found in the member&#39;s medical chart, or the absence of supporting documentation. Referring to  FIG. 9 , a sample “member condition” profile page with an incorrect condition status is shown. A review of the member&#39;s medical record may confirm the member had unstable Angina and Other Acute Ischemic Heart Disease during Year 115 while the member condition profile indicates the condition is a “provider denied condition”  230 . The user may select the “affirm” option  230  to change the condition status. 
         [0034]    Referring to  FIGS. 10A-10C , sample “provider affirm condition” pages according to an example embodiment are shown. The user may change the condition status to provider affirmed by providing the input requested on the page. The STAR application notifies the user if the input (e.g., date of service) is outside an expected range for the specified CMS year or if it is entered incorrectly. When the user is finished providing the requested data, selection of the “confirm” option causes the member&#39;s condition profiled to be refreshed with the appropriate indicator  232  as shown in FIG.  10 D. As shown in  FIG. 10D , the member&#39;s condition profile shows HCC 82 is a “provider affirmed condition”  232 . 
         [0035]    Report options include an activity log report that displays all activity (conditions which have been updated in the STAR database) for the provider(s) selected in the provider list window  240 . The user may specify date parameters by selecting “From and To” dates  242 . Referring to  FIG. 11 , a sample activity report page according to an example embodiment is shown. The report details  244  comprise the following: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 4 
               
               
                   
               
               
                 Activity Log Details 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Member Name 
                 (displays members who have been updated in 
               
               
                   
                 the STAR database during the period for 
               
               
                   
                 which the report was generated) 
               
               
                 Member ID 
                 unique member identifier 
               
               
                 DOB 
                 member date of birth 
               
               
                 HCC ID 
                 condition updated in the STAR database for 
               
               
                   
                 this member 
               
               
                 HCC 
                 condition description for condition updated 
               
               
                 Description 
                 in the STAR database 
               
               
                 Provider ID 
                 primary care physician associated with the 
               
               
                   
                 member that was updated 
               
               
                 User Name 
                 STAR application user that performed the 
               
               
                   
                 update to this member 
               
               
                 ICD9 
                 diagnosis detail applicable to those conditions 
               
               
                   
                 that were “affirmed” during the period for 
               
               
                   
                 which the report was generated 
               
               
                 Date of 
                 applicable to those conditions that were “affirmed” 
               
               
                 Service 
                 during the period for which the report was generated 
               
               
                 Update Date 
                 date that the condition was updated in the STAR database 
               
               
                 Status 
                 action that was performed for the updated condition 
               
               
                   
               
             
          
         
       
     
         [0036]    The activity log also displays a summary of total “affirmed conditions” and total “denied conditions” updated during the period for which the report was generated. 
         [0037]    Referring to  FIG. 12 , a sample condition status report page according to an example embodiment is shown. This report calculates and displays current condition status summary information and calculates an average risk score per member at three different levels: individual provider, provider group, and market. The condition status report displays information associated with the provider(s) selected in the provider list window on the main STAR application screen. Summary information displayed on the condition status report is as follows: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 5 
               
               
                   
               
               
                 Condition Status Report Details 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Member Counts 
                 total number of membership associated with 
               
               
                   
                 provider(s) 
               
               
                 Open Suspects 
                 total suspects identified during the current 
               
               
                   
                 period 
               
               
                 Open CMS 
                 total suspects that were “CMS accepted” 
               
               
                 Accptd. 1st 
                 conditions from prior period 
               
               
                 Prior Period 
               
               
                 Open CMS 
                 total suspects that were “CMS accepted” 
               
               
                 Accptd. 2nd 
                 conditions from two prior periods 
               
               
                 Prior Period 
               
               
                 Provd. Cont. 
                 total suspects for which the provider has 
               
               
                   
                 been contacted, but provider has neither 
               
               
                   
                 affirmed or denied the condition 
               
               
                 Provd. Affirmd. 
                 total suspects the provider has affirmed - 
               
               
                   
                 no supporting claim or encounter has yet 
               
               
                   
                 been received 
               
               
                 Provd. Denied 
                 total suspects the provider has denied 
               
               
                 CMS Accptd. 
                 total conditions that have been accepted by 
               
               
                 No Provd. Cont. 
                 CMS; provider was never contacted 
               
               
                 CMS Accptd 
                 total conditions that have been accepted by 
               
               
                 Provd Cont. 
                 CMS; provider was contacted 
               
               
                 CMS Accptd. 
                 total conditions that have been accepted by 
               
               
                 No Suspect 
                 CMS; condition was not previously a Suspect 
               
               
                 CMS Total 
                 total of all “CMS accepted” conditions 
               
               
                 Accptd. Count 
               
               
                 Cond. Per 
                 average number of conditions per member 
               
               
                 Member 
               
               
                 Avg. Risk 
                 average risk score per member 
               
               
                 Factor 
               
               
                   
               
             
          
         
       
     
         [0038]    Referring to  FIG. 13A , a sample request member listing report page according to an example embodiment is shown. The options on the page provide a user with the ability to display a list of members for which medical records need to be obtained for research. The report data membership is based upon search member status criteria (e.g., members with open conditions, members with affirmed conditions, members with “CMS accepted” conditions, members with conditions and members with no conditions) selected on the main STAR application screen (the member page). There are two available print criteria options for the member listing report  250 : 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 6 
               
               
                   
               
               
                 Member Listing Report Options 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Complete List 
                 lists entire provider membership for the search member 
               
               
                   
                 status criteria selected (includes members not currently 
               
               
                   
                 displayed in member list window) 
               
               
                 Displayed List 
                 lists the provider membership currently displayed in 
               
               
                 (100 Max) 
                 the member list window for the selected search member 
               
               
                   
                 status criteria 
               
               
                   
               
             
          
         
       
     
         [0039]    Referring to  FIG. 13B , a sample member listing report page according to an example embodiment is shown. 
         [0040]    Referring to  FIG. 14 , a sample “member not updated” report page according to an example embodiment is shown. This report provides the user with the ability to display a list of members that have not been updated (conditions “affirmed” or “denied”) in the STAR database. The report data membership is based upon the provider(s) selected in the provider list window on the main STAR application screen (the member page). There are two available print criteria options for the “members not updated” report  260 : 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 7 
               
               
                   
               
               
                 Members Not Updated Report Options 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Current Year 
                 lists members with open conditions in the current CMS 
               
               
                   
                 period that have not been updated in the STAR database 
               
               
                 Prior Year 
                 members with open conditions for the previous CMS 
               
               
                   
                 reporting period that have not been updated in the STAR 
               
               
                   
                 database 
               
               
                   
               
             
          
         
       
     
         [0041]    Referring to  FIG. 15 , a sample “unresolved level one conditions” report according to an example embodiment is shown. This report provides the user with the ability to display a list of members that have open (unresolved) “level one” conditions. Based on the provider(s) selected in the provider list window on the main STAR application screen, this report captures information at a “condition level” of detail. A member having multiple open “level one” conditions appears on this report multiple times with a separate row for each condition. There are two available print criteria options for the Unresolved “level one” report: 
         [0000]    
       
         
               
             
               
               
             
           
               
                 TABLE 8 
               
               
                   
               
               
                 Members with Unresolved “level one” Condition Report Options 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Current Year 
                 lists members with open “level one” conditions for the 
               
               
                   
                 current CMS reporting period 
               
               
                 Prior Year 
                 lists members with open “level one” conditions for the 
               
               
                   
                 previous CMS reporting period 
               
               
                   
               
             
          
         
       
     
         [0042]    The computerized system and method of the present disclosure facilitates reimbursements for healthcare services by allowing healthcare providers to access data for members of a health benefits plan and by allowing the healthcare providers to affirm or deny “suspect” health conditions for member records. The affirmation or denial of the presence of various health conditions within the member population along with revised encounter submissions may be used to project reimbursements to the healthcare providers for the services they provide to the members. The computerized system and method facilitates complete and accurate coding of medical records for use in projecting reimbursements to healthcare providers. 
         [0043]    While certain embodiments of the present invention are described in detail above, the scope of the invention is not to be considered limited by such disclosure, and modifications are possible without departing from the spirit of the invention as evidenced by the claims. For example, elements of the user interface may be varied and fall within the scope of the claimed invention. Various aspects of data collection and presentation may be varied and fall within the scope of the claimed invention. One skilled in the art would recognize that such modifications are possible without departing from the scope of the claimed invention.