Inventors:
Matthew P. Shults - Fountain Valley CA
Scott R. Smith - Aliso Viejo CA
Diane C. Altwies - Irvine CA
Michelle T. Delizio - Laguna Beach CA
Robert L. Kaaren - Laguna Beach CA
Mishel E. Munayyer - Mission Viejo CA
International Classification:
G06F 1760
Abstract:
A medical cost containment system for ensuring that the anticipated cost savings from utilization review (UR) agreements are actually realized. The UR agreements are essentially contractual agreements that specify the type and quantity of medical treatments relating to a specific claim resulting from a specific injury. Each UR agreement comprises a claim number, a procedure code describing the particular medical service authorized, and some indication as to dates or quantity of service authorized. All of the UR agreements are stored in a UR database. When a medical bill is received by the insurance company, the bill is entered in to the computer. The cost containment system searches all UR agreements in the UR database which have the same claim number as the claim number on the bill. For each item in the medical bill, the system finds the UR agreement which most closely matches the procedure code in the line item and various other criteria, such as the dates of treatment. The system then checks to ensure that the item in the bill is authorized by the UR agreement.