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Method for Using Health Care Claims Data to Deduce the Terms of Contracts for Payment Between Health Plan Administrators and Health Care Providers
Method for Using Health Care Claims Data to Deduce the Terms of Contracts for Payment Between Health Plan Administrators and Health Care Providers
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机译：使用医疗保健理赔数据推断医疗保健计划管理者与医疗保健提供者之间的付款合同条款的方法
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摘要
The present invention provides a computer-method for using statistical analysis to deduce the details of an unknown deterministic branching data generating process (DGP) which, in the preferred embodiment, is the claims processing algorithm used by a health plan administrator. The computer-method, in the preferred embodiment, includes accessing data on paid health care claims; splitting the claims data into subsets with a separate subset for each combination of health plan administrator, broad type of service (e.g. inpatient hospital care), and health care provider; defining possible contract types; identifying links among claims that reveal possible specific contracts; identifying a best specific contract for each claim; and running a partitioning tree model using the best specific contract for each claim as a categorical outcome to be predicted and including as predictors the date of service, the type of service, and other characteristics of the service.
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