COMPUTER-IMPLEMENTED METHOD FOR PROFILING MEDICAL CLAIMS

A computer-implemented program for profiling medical claims to assist health care managers in determining the cost-efficiency and service quality of health care providers. The software program allows an objective means for measuring and quantifying health, care services. An episode treatment group (ETG) is a patient classification system with groups that are clinically homogenous (similar cause of illness and treatment) and statistically stable. ETG grouper software uses service or segment-level claim data as input data and assigns each service to the appropriate episode. The program identifies concurrent and recurrent episodes, flags records, creates new groupings, shifts groupings for changed conditions, selects the most recent claims, resets windows, makes a determination if the provider is an independent lab and continues to collect information until an absence of treatment is detected.