US20110077980A1 - Automated processing of electronic medical data for insurance and disability determinations - Google Patents

Abstract

Methods and systems are described for automated processing of medical data for insurance and disability determinations. Based on medical conditions claimed by a claimant, medical evidence queries are automatically generated to provide instructions to medical providers for conducting physical exams and laboratory tests and for retrieving medical records. After medical evidence is collected according to the queries, the medical evidence and related rating codes and decisions are displayed to rating personnel in a user-friendly format to assist in making a rating decision.

Description

REFERENCE TO RELATED APPLICATIONS
• The present application is a continuation of and claims priority benefit under 35 U.S.C. §120 from U.S. patent application Ser. No. 12/767,778, filed Apr. 26, 2010, which is a continuation of and claims priority benefit under 35 U.S.C. §120 from U.S. patent application Ser. No. 11/157,125, filed Jun. 20, 2005, which issued as U.S. Pat. No. 7,707,046, which is a continuation-in-part of and claims priority benefit under 35 U.S.C. §120 from U.S. patent application Ser. No. 10/279,759, filed Oct. 23, 2002, which issued as U.S. Pat. No. 7,630,911, which claims priority benefit under 35 U.S.C. §119(e) from U.S. Provisional Application No. 60/344,663, filed Oct. 25, 2001, and U.S. Provisional Application No. 60/345,998, filed Oct. 24, 2001, each of which is hereby incorporated herein by reference in its entirety.
• Government agencies and insurance companies have developed rules for adjudication of insurance or disability requests. Examples of insurance or disability programs include the Department of Veterans Affairs (VA) program, the Social Security Disability Insurance program, the Workers' Compensation program, various property and casualty insurance programs, and so forth.
BACKGROUND OF THE INVENTION
• 1. Field of the Invention
• The present invention relates to methods and systems for gathering and processing medical data to support rating decisions in the adjudication of insurance and disability requests.
• 2. Description of the Related Art
• In order to adjudicate a request made by a claimant, certain medical evidence is required. Medical evidence requirements refers to requirements of information about a claimant that is relevant to the medical conditions claimed by the claimant, such as the age and gender of the claimant, physical examination data, laboratory test data and medical history data pertinent to the claims, and so forth. The requirements are specified by rules developed by the government agency or by the insurance company, pertinent case law, government regulations, legislation and administrative decisions, and so forth. For example, the requirements may specify that if a claimant claims a certain medical condition, a medical provider must conduct certain physical examinations and laboratory tests on the claimant or ask certain questions. The requirements may also specify, for example, that a claimant must have a range of motions less than a certain degree to claim a limb disability. Requirements can also be specified by conventional medical knowledge, for example requiring a certain test to confirm a particular claimed condition.
• The rating rules are normally documented in manuals that may have many different titles, herein referred to as “rating books.” A rating code refers to a classification used by the government agency or insurance company that typically refers to a medical condition or a class of medical conditions in a rating book. The collection of rating rules, rating codes, pertinent legislation and case law for an insurance or disability program is herein referred to as the “rules collection” for that program. The rating rules may include rules on how to make a rating decision based on the collected medical evidence and the rating codes. For example, in a V.A. disability program, the rules collection typically specifies a disability percentage range based on rating codes and collected medical evidence. A V.A. rating personnel reviews the rating codes and medical evidence, and specifies a disability percentage within the range.
• In a disability or insurance request process, the claimant typically visits a hospital, clinic or medical office. A medical provider such as a physician or a nurse collects medical evidence from the claimant to support a rating decision. The rating decision is typically made by the government agency or the insurance company based on the medical evidence collected by the medical provider and based on the rules collection. The medical providers are typically provided with documents generally referred to as “physician's disability evaluation” or “medical examination handbooks” to assist them with collecting medical evidence. The handbooks are herein referred to as “medical handbooks”. The medical handbooks typically contain the medical evidence requirements for the rules collection.
• Whereas the rating books are typically intended for the rating personnel in the government agency or insurance company, the medical handbooks are typically intended for the medical providers. Although they are somehow related, the rating books and medical handbooks typically contain very few direct cross-references. In addition, the medical providers often are not familiar with the rules collection of the insurance or disability program, and make mistakes in using the medical handbooks. Therefore, the required medical evidence can be omitted or entered incorrectly, thus affecting the making of a correct rating decision. In addition, the rating personnel, who typically have only limited medical knowledge, must spend considerable time to review the medical information collected by the medical providers. What is desired is an automated system that provides instructions to medical providers to collect medical evidence based on the rules collection of the insurance or disability program. What is also desired is a system that provides supporting information in a user-friendly format to assist rating personnel in making a rating decision based on the collected medical evidence.
• In many cases, a claimant makes claims for multiple medical conditions. The conventional practice is to complete a medical evidence document for each claimed condition. This results in significant duplication of effort as duplicate medical data is gathered and identical medical procedures might be conducted multiple times. Therefore, what is desired is a system that eliminates the duplications.
• To better illustrate the drawbacks of conventional practices and the need for better systems, the VA Compensation and Pension (C&P) program is described as an example. This government program provides payments of benefits to military veterans for medical disability resulting from their military service. The rating rules are included in the Code of Federal Regulations 38-CFR, the governing legislation, and in a rating book. The related medical handbook is a series of documents titled Automatic Medical Information Exchange (AMIE) worksheets. These worksheets specify the medical evidence required and the procedures to be utilized for each claimed condition included in 38-CFR. There are currently over fifty separate AMIE worksheets covering a wide array of claims, from a Prisoner of War Protocol Examination to Scars Examination. Each worksheet is designed as a stand-alone medical document for the particular claimed disability. In addition to the AMIE worksheets, legislatively mandated requirements, administrative requirements, and court ordered information have, from time to time, specified other medical evidence or dictated the manner in which it is to be collected. Significant training and experience is required to familiarize medical providers with the worksheets and the additional requirements. Significant delays and extra cost in claims processing are encountered when required medical evidence is not provided or incorrect procedures are conducted. Additionally, the claimant frequently claims multiple disabilities. These can number up to twenty or more claims for one claimant. The current practice is to complete an AMIE worksheet with all the requirements for each claimed disability. This results in unnecessary duplication of procedures with the entailed extra costs and time.
SUMMARY OF THE INVENTION
• One aspect of the invention relates to a computer-implemented method of assisting the collection of medical evidence for adjudication of a medical disability request. At least one claim of a medical condition is received by a claimant into a storage. Based on the at least one claim and based on a disability rules collection, a plurality of medical evidence queries are automatically generated. Medical evidence data is received from a first electronic data storage into a second storage, said medical evidence data being responsive to at least one of the generated medical evidence queries.
• Another aspect of the invention relates to a computer-implemented method for facilitating adjudication of a medical disability request. Medical evidence data concerning a claimant is received. A disability rating report is automatically generated based on the medical evidence data. The medical evidence data is preferably obtained by a method comprising the following steps. At least one claim by a claimant of a medical condition is received into a first storage. A plurality of medical evidence queries is automatically generated based on the at least one claim and based on a disability rules collection. Answers to the generated medical evidence queries from an electronic data storage are received into a second storage, said answers corresponding to the medical evidence data.
• Still another embodiment relates to a computer system comprising a computer-readable medium having stored thereon computer-executable instructions for performing the following method. At least one claim of a medical condition is received from a claimant. A plurality of medical evidence queries is generated based on the at least one claim and based on a disability rules collection. Medical evidence data corresponding to the generated medical evidence queries is received from an electronic data storage.
• Yet another embodiment relates to a computer-readable medium having stored thereon computer-executable instructions for performing the following method. At least one claim of a medical condition is received from a claimant. A plurality of medical evidence queries is generated based on the at least one claim and based on a disability rules collection. The generated medical evidence queries are displayed in at least one data collection protocol.
• For purposes of summarizing the invention, certain aspects, advantages and novel features of the invention have been described herein. Of course, it is to be understood that not necessarily all such aspects, advantages or features will be embodied in any particular embodiment of the invention.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 illustrates the general overview of one embodiment of a disability benefits claims system.
• FIG. 2 illustrates one embodiment of an arrangement of modules and sub-modules.
• FIG. 3 illustrates one embodiment of an arrangement of categories and sub-categories.
• FIG. 4 illustrates one embodiment of a process of organizing rules collection into a knowledge library.
• FIG. 5 illustrates one embodiment of a process of generating claimant-specific medical evidence queries.
• FIG. 6 illustrates one embodiment of a data entry form for claimed medical conditions.
• FIGS. 7A-7D illustrate one embodiment of a medical provider's exam protocol.
• FIGS. 8A-8E illustrate one embodiment of a claimant questionnaire.
• FIGS. 9A-9B illustrate one embodiment of a narrative medical report.
• FIG. 10 illustrates one embodiment of a diagnostic code summary medical report.
• FIGS. 11A-11H illustrate one embodiment of a rating report.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
• To better illustrate the invention, certain embodiments of the invention are described below in connection with the drawings. It should be understood that the scope of the invention is not limited by these embodiments but defined by the claims.
• Overview of Disability Benefits Claims System
• FIG. 1 illustrates the general overview of one embodiment of a disability benefits claimssystem100. Therules collection112 for the insurance or disability program and pertinentmedical knowledge114 are organized by aFID mapping component116 into aknowledge library118. Based on the claimedmedical conditions120 from a claimant and based on the rules collection or medical knowledge stored in theknowledge library118, the claimant-specificquery creation module122 creates claimant-specific medical evidence queries.
• The queries are then separated into medical record queries124 for medical records, and exam queries126 for physical exams and laboratory tests. The medical record queries124 for medical records may be used by the clerk'sprotocol creation component134 to create a clerk's data collection protocol to collect the required data from medical records. Alternatively, the medical record queries124 may trigger an electronic records querying component (not shown) that facilitates the collection of the required data from electronic medical records (EMR) stored in theclaimant database160.
• The exam queries126 for exams and tests may be used by the medical provider's examprotocol creation component136 to create a medical provider's data collection protocol to assist a physician, nurse or technician in reviewing and extracting data from charts, radiological study results, nuclear medicine laboratory results, present medication, allergy and chronic condition lists (e.g., from medical alert bracelets) and other medical records of the patient. The examprotocol creation component136 may also be used to create a medical provider's data collection protocol to assist the medical provider in conducting histories of the present illness, past medical histories, family and social histories, a review of systems, physical exams, laboratory tests, interviews with friends and family of the claimant, and interviews of the claimant's prior medical providers. Thecomponent136 may also use the exam queries126 to create a questionnaire to be answered by the claimant. The medicalreport creation component142 uses the medical evidence collected from exams, tests, reviews, histories, interviews, claimant questionnaires and medical records to create a medical report. The ratingreport creation component152 creates a rating report to assist rating personnel in adjudicating the claims. The collected medical evidence can also be stored in theclaimant database160.
• Organizing Rules Collection into Knowledge Library
• Still referring toFIG. 1,component112 represents the rules collection for the insurance or disability program, typically embodied in rating books, legislation, administrative decisions and case law.Component114 represents pertinent medical knowledge, such as instructions to a physician, lab technician or nurse for performing a physical exam or laboratory test. The rules collection and medical knowledge are organized by aFID mapping component116 into FIDs and stored in aknowledge library component118.
• In a preferred embodiment, every unit of data that may be required by the rules collection for making a rating decision is identified by a field identification number (FID). Examples of FID data fields include a “patient name” field, a “heart rate” field, a “impaired limb motion range” field, and so forth. Each general medical evidence query is identified by a FID. A general medical evidence query corresponds to a medical evidence requirement specified by the rules collection or by medical knowledge. A claimant-specific medical evidence query is generated from the general medical evidence queries and based on the claimant's claimed medical conditions. Claimant-specific queries are described in the subsection titled “Generating claimant-specific medical evidence queries”.
• In a preferred arrangement, each FID includes a category code, a rating code and a data query code, separated by the underline symbol “_”. For example, a FID can take the form of “H047_SM500_T001”. The category code “H047” identifies the FID to a category of queries concerning the right knee. The rating code “SM500” identifies the FID to a particular rating code for musculoskeletal injuries in a rating book. The data query code “T001” identifies the FID to the data query “What is the range of motion?.” In another example, the FID mapping number is “TK10_TS6600_T001”. The category code “TK10” represents a category of queries concerning bronchitis. The rating code “TS6600” represents a rating book rating code “6600”. The data query code “T001” represents the query “What is the FEV1 value?.” A query text table stores the data query codes and the query text for each of the data query codes. The table may also store a long instruction text for each data query code as an instruction or explanation. The stored query text and long instruction text can be later displayed in a medical provider's exam protocol, history or interview protocol, claimant questionnaire, clerk's data collection protocol, medical report or rating report.
• A FID can take other forms. For example, in a relational database arrangement, a rating code table can store the rating code for each data query code, and a category code table can store the category code for each data query code. Therefore a FID need only include a data query code, and the rating code and category code for the FID can be identified by referencing the rating code table and the category code table. In an object-oriented arrangement, a FID can be an object that includes a data query object field, a rating code object field and a category code object field.
• TheFID mapping component116 organizes the rules collection into a plurality of FIDs. For example, for a rating code that identifies diabetes in a V.A. rules collection, thecomponent116 creates a plurality of FIDs, with each FID identifying a unit of medical evidence required for making a rating decision on the diabetes claim. Each FID preferably includes a category code, the V.A. rating code that identifies diabetes, and a data query code. For example, one FID includes a data query code representing the data query “Have you served in the Vietnam War?” because V.A. rules assume that Vietnam veterans' diabetes conditions are caused by exposure to Agent Orange. As described above, the data query code may be further associated with a long instruction text “If claimant has served in Vietnam and suffers from diabetes, assume that service connection exists.”
• Arrangement of Modules and Sub-Modules, Categories and Sub-Categories
• FIG. 2 illustrates one embodiment of a disability benefits claimssystems100 that includes modules and sub-modules. A rating book typically classifies medical conditions into disease systems, also called body systems. Typical disease systems may include the cardiovascular system, the respiratory system, infectious diseases, and so forth. Some rating books classify a disease system into one or more sub-disease systems or sub-body systems. For example, a “cardiovascular disease system” may include sub-disease systems such as myocardial-infarction sub-disease system, arrhythmia sub-disease system, and so forth. A sub-disease system is typically unique to one disease system and is not shared by multiple disease systems.
• As shown inFIG. 2, each sub-disease system is mapped to one or more modules of the disability benefits claimssystem100. A module represents a function within the sub-disease system. For example, the lung sub-disease system can be mapped to a “history of symptoms” module, a “history of general health” module, a “physical examination of the lungs” module, and so forth. In one embodiment, sub-disease systems can share common modules. In one embodiment, modules are assigned priority numbers that identify a priority order among the modules.
• Each module can include one or more sub-modules. For example, a “vital signs” sub-module can include data about the height, weight, pulse, and blood pressure of the claimant. A sub-module includes one or more FIDs. Modules can share common sub-modules. For example, the “vital signs” sub-module can be shared by multiple modules because vital signs information is needed for the diagnosis of many diseases and conditions. In one embodiment, sub-modules are assigned priority numbers that identify a priority order among the sub-modules.
• A sub-module includes one or more FIDs. For example, the “vital signs” sub-module includes a “height” FID, a “weight” FID, a “pulse” FID and a “blood pressure” FID. In a preferred embodiment, each FID belongs to only one sub-module. In one arrangement, each FID includes a sub-module code that identifies the sub-module of the FID. In another embodiment, a sub-module table in theknowledge library118 stores the FIDs for each sub-module.
• In other embodiments, modules and sub-modules are not introduced. Each rating code and its general medical evidence queries directly correspond to a collection of FIDs. The FID collections for two rating codes may share one or more FIDs.
• Referring toFIG. 3, the unique data elements that make up the rules collection are grouped by category and sub-category. The categories and sub-categories preferably relate to classifications in the rating books. For example, categories can include “General”, “Complications”, “Function”, “Symptoms”, “Tests”, and so forth. A category can be further classified into one or more sub-categories. For example, the “Function” category includes the sub-categories “ability” and “restriction”. The “Tests” category can include sub-categories “confirmation,” “essential,” “indication,” and “results.” A sub-category includes one or more FIDs.
• FIG. 4 illustrates one embodiment of a process of organizing rules collection into FIDs. From astart block410, the process proceeds to ablock420 to identify rating codes from the rating books for the disability or insurance program. The process then proceeds to ablock430 to identify data fields within each rating code. Each data field represents a general medical evidence query. Data fields may also be identified based on pertinent medical knowledge, for example the knowledge of a experienced physician that certain medical evidence are needed to make a rating decision for a particular rating code. Data fields may also be identified based on case law and administrative decisions, for example the Deluca case and required “Deluca issues.”
• The process then proceeds to a block440 to group the data fields by category. In another embodiment, data fields are grouped by sub-category. The process proceeds to ablock450, where a FID is assigned to each data field. In a preferred embodiment, a category code, a rating code and a data query code is assigned to each FID. The category code represents the category the data field is grouped into. The rating code represents the rating code for the data field. The data query code represents the data query for the medical evidence query. The process then proceeds to ablock460 to store the FIDs in aknowledge library component118. The process terminates at anend block470.
• Generating Claimant-Specific Medical Evidence Queries
• InFIG. 1, the claimant-specificquery creation module122 receives the claimedmedical conditions120 from the claimant, and creates claimant-specific medical evidence query based on the claims and by referring to the general medical evidence queries stored in theknowledge library118. As would be well-understood by those of skill in the art, the claimedmedical conditions120 might comprise physical, psychiatric, substance abuse disorders or other abnormalities, and are typically stored in any of a variety of computer-readable storage media.FIG. 5 illustrates one embodiment of the query-creation process.
• Referring toFIG. 5, the process starts from astart block510 and proceeds to ablock520, where thequery creation component122 receives one or more claims of medical conditions from the claimant. In one embodiment, thecomponent122 also receives other information provided by the claimant, for example information such as claimant name, age, gender filled out by the claimant on a data entry form form.FIG. 6 is an example data entry form. It can be filled out by the claimant or by a clerk. The “Special Instructions to the Doctor” section displays special instructions retrieved from theknowledge library118 for the particular insurance or disability program and displayed as a reminder to the medical provider.
• Referring back toFIG. 5, at ablock530, thecomponent122 identifies the related modules based on the received claims. For example, if the claimed condition is “loss of eyesight,” thecomponent122 may identify a “physical exam” module and a “neurological exam” module. The relationships of medical conditions and related modules are stored in theknowledge library118. Thecomponent122 also identifies all sub-modules of the identified modules. If two of the identified modules share common sub-modules, the duplicate sub-modules with the lower priority numbers are removed. From all of the FIDs that belong to the identified modules, the duplicate FIDs can also be removed. In other embodiments, instead of identifying the related modules based on the received claims, thecomponent122 identifies the related sub-modules, the related categories, or the related sub-categories. In another embodiment, thecomponent122 directly identifies the related FIDs stored in theknowledge library118 based on the received claims.
• At ablock540 ofFIG. 5, thecomponent122 selects those FIDs in theknowledge library118 that belong to the identified modules and sub-modules. The selected FIDs form a set of the claimant-specific medical evidence queries. The set can be stored in a variety of formats, for example as a text string with FIDs separated by field delimiters such as colons or semicolons, as a text file with a FID in each line, as a table with each FID as a record, as a series of objects with each FID having a “next FID” pointer that points to the next FID object, and so forth. This set of queries is preferably stored in a computer-readable storage, such as hard disk storage, solid state RAM, etc, and this data storage may be implemented using any type of computer storage device or devices, and using any type or types of data repositories (e.g., relational databases, flat files, caches, etc.).
• In one embodiment, thecomponent122 compares the information already received from the claimant, and fills the related FIDs with such information. For example, if the claimant has provided his or her name, age and gender, the component then fills the related FIDs with the claimant-provided information. The details of filling a FID with collected medical evidence are described below in more detail.
• From theblock540, the process proceeds to ablock550, where thecomponent122 determines which of the generated claimant-specific queries may be satisfied from medical records. In another embodiment, a human operator reviews the generated queries and determines which of the queries may be satisfied from medical records. In still another embodiment, thecomponent122 accesses a claimant's EMR and determines which generated claimant-specific queries may be satisfied from the EMR. In other embodiments, instead of determining on a per FID basis, the determination can also be made on a per module, per sub-module, per category or per sub-category basis.
• If all generated queries may be obtained from medical records, electronic or paper-based, then the process proceeds to block570. Otherwise the process proceeds to ablock560, where thecomponent122 generates a set of claimant-specific queries to be satisfied from physical exams, histories and interviews, claimant questionnaires, laboratory tests, or other medical provider input. At theblock570, thecomponent122 generates a set of queries whose results can be obtained from existing medical records. The claimant-specific queries generated at theblock540 are thus separated into two sets of queries. In another embodiment, the queries generated at theblock540 are separated into three sets: one set of queries to be satisfied from physical exams, histories, interviews and claimant questionnaires, another set to be satisfied from laboratory tests, and a third set to be satisfied from medical records.
• Referring back to theblocks530 and540 ofFIG. 5, when the claimant submits claims for multiple conditions, it is possible that some of the modules are identified more than once by the claims. Thecomponent122 searches for duplicate modules and eliminates such duplications. In other embodiments, the component can also search for and eliminate duplications on the sub-module or FID level.
• Each module is associated with a priority number stored in theknowledge library118. In the case where multiple modules are called that examine the same sub-disease system, the duplicate modules with the lower priority numbers are eliminated. In another embodiment, each FID is associated with a priority number stored in theknowledge library118.
• In one embodiment, the generated queries can be updated by a human operator. For example, a medical provider or rating personnel reviews the generated claimant-specific queries and adds, modifies or deletes one or more queries. This allows some flexibility and human control in thesystem100. The human operator can also change the order of generated claimant-specific queries determined by the priority numbers.
• Thecomponent122 also checks special rules stored in theknowledge library118 for exceptions and updates. Exceptions and updates are typically caused by changes in legislation, case law, and insurance or disability program rules. For example, special rules that represent the Deluca case decision can be stored in theknowledge library118. The stored Deluca special rules can be associated with FIDs, categories or modules stored in theknowledge library118. When the generated claimant-specific queries include a FID associated with a special rule, the special rule is retrieved from theknowledge library118 and applied to include a special rule instruction with the FID, or to add, modify or remove other claimant-specific queries. The special rule can also change the order of generated claimant-specific queries determined by the priority numbers.
• Creating Medical Provider's and Clerk's Data Collection Protocols
• Referring back toFIG. 1, based on the generated set of claimant-specific queries for exams, the medical provider'sprotocol creation component136 may create a medical provider's data collection protocol, also called a physician's exam protocol. Thecomponent136 may also create a claimant questionnaire based on the claimant-specific queries. Based on the generated set of claimant-specific queries for medical records, the clerk'sprotocol creation component134 may create a clerk's data collection protocol. The generated set of claimant-specific queries may also trigger an electronic records querying component (not shown) that facilitates the collection of the required data from EMR.
• FIGS. 7A-7D illustrate an example medical provider's data collection protocol. The protocol lists the claimant-specific medical evidence queries to be satisfied from physician exams and laboratory tests. In the embodiment shown inFIGS. 7A-7D, the queries are grouped by category and sub-category. For example, the category “PHYSICIAL EXAMINATION” shown inFIG. 7A includes sub-categories “VITAL SIGNS”, “HEENT”, “EYES”, “SKIN”, “HEART”, and “MUSCULOSKELETAL SYSTEM”. The grouping of categories and sub-categories presents the queries in a user-friendly order to the medical provider.
• The medical provider uses the exam protocol to examine the claimant, and preferably enters collected medical evidence into the protocol. In one embodiment, the exam protocol is displayed to the medical provider on the screen of an electronic device such as a computer or a personal digital assistant, and the medical provider enters the collected medical evidence corresponding to each query into the electronic device. In another embodiment, the exam protocol is displayed to the medical provider in a paper report, and the medical provider enters the collected medical evidence on the paper report for a clerk to enter into a computer system.
• The medical evidence collected by the medical provider is then stored into the disability claimsbenefits system100. In one embodiment, for each generated claim-specific query and its FID, the corresponding medical evidence is simply inserted into the end of the FID. For example, for the FID “H047_SM500_T001” described above, if the medical provider determines that the range of motion is 90 degrees, then the FID becomes ““H047_SM500_T001_—90”, with the last field within the FID storing the value of the medical evidence. In another embodiment, a table includes a “original FID” field that stores the FID of each query, and a “data value” that stores the medical evidence value of the corresponding FID. Other embodiments can also be implemented.
• To replace or to supplement the physician's exam protocol, thecomponent136 may create a claimant questionnaire for those queries that can be satisfied by collecting answers directly from the claimant.FIGS. 8A-8E illustrate an example claimant questionnaire. The questionnaire can be filled out in paper or electronic form, by the claimant or by a clerk assisting the claimant. The questionnaire displays generated claimant-specific queries that can be satisfied by collecting answers from the claimant. The data entered into the questionnaire is then stored as collected medical evidence corresponding to the displayed queries. The data can be stored with the FIDs as described above, and preferably displayed to the physician for review or verification.
• The clerk's data collection protocol displays generated claimant-specific queries that are to be collected from medical records. For each query, the protocol preferably displays an instruction to the clerk, for example “retrieve data from previous x-ray charts.” The instructions can be retrieved from instructions stored in theknowledge library118 that are associated with stored general medical evidence queries. In another embodiment, the system automatically notifies a custodian of medical records via email, voice mail or paper report to search for the medical evidence specified by the queries.
• In yet another embodiment, the disability benefits claims system is connected to an electronic data storage that stores existing medical records as EMR, in, for example, aclaimant database160. The electronic data storage may comprise any type of computer-readable media, including hard disk drives, removable magnetic disks, removable optical disks, magnetic cassettes, flash memory cards, digital video disks, Bernoulli cartridges, random access memories, read-only memories, and the like. The claims system, via an electronic records querying component (not shown), may automatically search the data storage and collect required medical evidence from the EMR. If theclaimant database160 is encrypted, or if access to this database is otherwise restricted, the claims system may be configured to store the requisite authentication in order to access thedatabase160 freely. In another embodiment, the clerk or medical provider may be required to provide such authentication before the disability benefits claims system can access thedatabase160.
• The claims system may communicate with theclaimant database160 by any of a variety of electronic communications methods well known to those of skill in the art, including over a local area network, a wide area network, the internet (preferably an encrypted internet connection), a phone line, etc. As is well understood by those of skill in the art, the terms “over” and “through” in reference to network access are used synonymously; thus, one may access data over the internet or through the internet. In a preferred embodiment, theclaimant database160 stores medical evidence in a format that may easily be correlated to the medical evidence queries. For example, theclaimant database160 may be formatted to a particular standard that is widely adopted, and which facilitates access by other applications that have also adopted the particular standard (e.g., Snomed). However, in other embodiments, the claims system may comprise sophisticated protocols for querying the database and for correlating the queries with meaningful evidence.
• In order to improve the efficiency of the process, the claims system may first search the electronic data storage for medical evidence that is responsive to the generated claimant-specific queries. In one embodiment, the system may separate the exam queries from the medical record queries only after all possible claimant-specific queries have been answered using the evidence in the EMR. In another embodiment, as illustrated, theprotocols134,136 may be created before theclaimant database160 is interrogated. In another, transitional embodiment, the claims system may simultaneously search the electronic data storage, and also provide a clerk's protocol according to which the claimant-specific queries may be answered from older, paper-based medical records.
• Follow-Up Queries Based on Collected Medical Evidence
• Thequery creation component122 may create conditional claimant-specific queries. For example, if a required exam reveals an abnormal condition, then additional medical evidence may be required according to therules collection112 or according tomedical knowledge114. Such additional medical evidence queries are called conditional queries. The query whose medical evidence may trigger the conditional queries is called a triggering query. A triggering query may be associated with one or more sets of conditional queries. For example, a positive result of a laboratory test for a triggering query requires a first set of conditional queries, and a negative result may require a second set of conditional queries.
• In one embodiment, the FID of a triggering query stored in theknowledge library118 includes a list of the FIDs of the conditional queries. In another embodiment, each query is stored as an object in theknowledge library118, and a triggering query object includes pointers to point to its conditional query objects. In yet another embodiment, the FID of a triggering query includes a flag code to indicate it is a triggering query. A triggering query table includes a first field that stores the FID of a triggering query and a second field that stores the FIDs of the corresponding conditional queries. In each embodiment, theknowledge library118 may also store a triggering rule that indicates under what conditions the conditional queries are needed, for example “when the triggering query returns a positive test result” or “when the triggering query's medical evidence is not available.”
• Regardless of the storage embodiments, when the claimant-specificquery creation component122 generates a triggering query as a claimant-specific query, the conditional queries for the triggering query are preferably also generated as claimant-specific queries. Theprotocol creation components134 and136 identifies a triggering query, and preferably displays its corresponding conditional queries immediately following the triggering query. The medical provider's exam protocol, clerk's data collection protocol and claimant's questionnaire preferably include instructions to explain the triggering rules, for example “if this test result is positive, then answer the following questions.”
• The conditional queries can be displayed after the medical evidence for the triggering query is collected. For example, a medical provider's exam protocol is displayed to the medical provider on the screen of an electronic device, and the medical provider enters collected medical evidence into the electronic device. As the medical provider enters the medical evidence for a triggering query into the electronic device, thesystem100 compares the entered medical evidence with the triggering query's triggering rule stored in theknowledge library118, and displays the conditional queries according to the triggering rule. If the conditional queries are to be collected from physical exams, they are displayed on the electronic device or on an additional paper report. The conditional queries can also be displayed on a claimant questionnaire or clerk's data collection protocol, in electronic or paper form.
• Creating Medical Report
• Referring back toFIG. 1, after medical evidence is collected from physical examinations, laboratory tests, medical records and claimant questionnaire, the collected medical evidence is used by a medicalreport creation component142 to create a medical report.FIGS. 9A-9B andFIG. 10 illustrate two example medical reports.FIGS. 9A-9B illustrate a sample narrative report. It includes collected medical evidence, for example medical history data and other data, in preferably a narrative form.
• FIG. 10 illustrates a sample diagnostic code summary report. For a claimed right knee medical condition, the report displays a summary of claimant-specific queries and medical evidences, and corresponding rating codes such as “5010” and “5003”. In one preferred embodiment described above, the FID for each query includes a category code, a rating code and a data query code. The rating code of the FID is thus displayed along with the collected medical evidence of the query. The report thus displays direct relationships of medical conditions, medical evidence and rating codes.
• The medical report can be used by medical providers to review the claimant's medical evidence and to familiarize the medical providers with the associated rating codes. The report can also be used by rating personnel to review the claimant's medical evidence and associated rating codes. In some embodiments, medical reports can be used interchangeably with rating reports, which are described below in connection withFIGS. 11A-11H.
• Depending on the insurance or disability program, reports of different formats can be generated to conform to the commonly accepted format of the particular program. For example, the medical evidence queries can be grouped by disease system on a report for a first insurance program, and grouped by module on another report for a second disability program.
• Creating Rating Report
• Referring back toFIG. 1, the ratingreport creation component152 creates a rating report to assist rating personnel to adjudicate the insurance or disability requests of the claimant.FIGS. 11A-11H illustrate an example rating report, also called a rating decision toolkit.
• In one embodiment, the ratingreport creation component152 also recommends a rating decision to the rating personnel. The rating decision can be generated based on a set of mathematical formulas, a rule-based system, an expert system, a self-learning neural network, a fuzzy logic system, and so forth. The recommended rating decision can be generated in the form of a numerical value representing a disability percentage, a numerical value representing the insurance benefits dollar amount, a binary value representing a decision to grant or deny an insurance request, and so forth. As shown inFIG. 11C, for the rating code “5259”, thecomponent152 recommends a V.A. rating of “10”, i.e., a disability percentage of 10%.FIG. 11G displays a summary of all rating codes and corresponding recommended disability percentages, and a recommended combined disability percentage. The rating personnel can review the rating report and accept, reject or modify the recommended ratings.
• The disclosed disability claims benefitssystem100 can be implemented in a variety of computer languages, commercial applications and operating platforms. For example, the system can be implement in whole or in part in Visual Basis, C, SQL, and so forth.
• Certain aspects, advantages and novel features of the invention have been described herein. Of course, it is to be understood that not necessarily all such aspects, advantages or features will be embodied in any particular embodiment of the invention. The embodiments discussed herein are provided as examples of the invention, and are subject to additions, alterations and adjustments. Therefore, the scope of the invention should be defined by the following claims.

Claims (19)

1. A system for adjudicating a medical disability request, comprising:

a computer-readable storage comprising:

at least one claim, from a claimant, of a medical condition;

a predetermined set of medical evidence queries; and

a disability rules collection; and

a computer processor configured to select a plurality of claim-type specific medical evidence queries from the set based on the at least one claim and the disability rating rules collection, to exclude queries, from the plurality of claim-type specific medical evidence, that are not specific to the claim or claim type, and to receive medical evidence data responsive to the selected plurality of queries;

wherein the set contains a greater number of queries than the plurality of queries.

2. The system ofclaim 1, wherein the computer processor is further configured to display the generated medical evidence queries in a data collection protocol.

3. The system ofclaim 1, wherein the medical evidence data is received from an electronic data storage comprising electronic medical records.

4. The system ofclaim 1, wherein the medical evidence data comprises responses to the selected medical evidence queries.

5. The system ofclaim 1, wherein the medical evidence data is collected by a medical provider.

6. The system ofclaim 5, wherein the medical evidence data collected by the medical provider comprises at least one of reviewing and extracting data from medical records, taking a medical history of the claimant, receiving data from a physical exam, receiving data representative of laboratory tests, receiving data from radiological study results, or receiving data from nuclear medicine laboratory results.

7. The system ofclaim 6, wherein the medical history comprises at least one of a family history and a social history.

8. The system ofclaim 1, wherein the computer processor is further configured to determine a degree of disability based on the medical evidence data and on the disability rating rules collection.

9. The system ofclaim 8, wherein the computer processor is further configured to generate a report comprising the degree of disability.

10. A method for adjudicating a medical disability request, comprising:

receiving at least one claim, from a claimant, of a medical condition;

selecting, using a computer processor and from a predetermined set of medical evidence queries, a plurality of claim-type specific medical evidence queries based on the at least one claim and a disability rating rules collection; and

receiving medical evidence data responsive to the selected plurality of queries;

wherein the selecting the predetermined set comprises excluding queries, from the plurality of claim-type specific medical evidence, that are not specific to the claim or claim type; and

wherein the set contains a greater number of queries than the plurality of queries.

11. The method ofclaim 10, further comprising displaying the selected medical evidence queries in a data collection protocol.

12. The method ofclaim 10, wherein the medical evidence data is received from an electronic data storage comprising electronic medical records.

13. The method ofclaim 10, wherein the medical evidence data comprises responses to the selected medical evidence queries.

14. The method ofclaim 10, wherein the receiving medical evidence data comprises receiving medical evidence data collected by a medical provider.

15. The method ofclaim 14, wherein the receiving medical evidence data collected by a medical provider comprises at least one of reviewing and extracting data from medical records, taking a medical history of the claimant, receiving data from a physical exam, receiving data representative of laboratory tests, receiving data from radiological study results, or receiving data from nuclear medicine laboratory results.

16. The method ofclaim 15, wherein the medical history comprises at least one of a family history and a social history.

17. The method ofclaim 10, further comprising determining a degree of disability based on the medical evidence data and on the disability rating rules collection.

18. The method ofclaim 17, further comprising generating a report comprising the degree of disability.

19. A computer-readable medium having computer-executable instructions stored thereon for performing method for adjudicating a medical disability request, comprising:

receiving at least one claim, from a claimant, of a medical condition;

selecting, using a computer processor and from a predetermined set of medical evidence queries, a plurality of claim-type specific medical evidence queries based on the at least one claim and a disability rating rules collection; and

receiving medical evidence data responsive to the selected plurality of queries;

wherein the selecting the predetermined set comprises excluding queries, from the plurality of claim-type specific medical evidence, that are not specific to the claim or claim type; and

wherein the set contains a greater number of queries than the plurality of queries.

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