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Insurance Abstract
The present invention relates to methods and systems for automated
processing of medical data for insurance and disability determinations.
Based on medical conditions claimed by the 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 are displayed to rating personnel in a user-friendly format
to assist in making a rating decision.
Insurance Claims
1. A computer-implemented method of assisting medical evidence collection
for adjudication of a medical disability request, the method comprising:
receiving from a claimant at least one claim of a medical condition;
generating a plurality of medical evidence queries based on the
at least one claim and based on a disability rules collection; and
displaying the generated medical evidence queries in at least one
data collection protocol.
2. The method of claim 1, further comprising receiving medical
evidence data collected according to the generated medical evidence
queries.
3. The method of claim 2, wherein receiving medical evidence data
comprises receiving medical evidence data collected by conducting
a physical examination of the claimant.
4. The method of claim 2, wherein receiving medical evidence data
comprises receiving medical evidence data collected by conducting
a laboratory test of the claimant.
5. The method of claim 2, wherein receiving medical evidence data
comprises receiving medical evidence data collected from medical
records of the claimant.
6. The method of claim 2, wherein receiving medical evidence data
comprises receiving medical history data of the claimant.
7. The method of claim 2, further comprising generating a report
based on the collected medical evidence data.
8. The method of claim 7, further comprising: generating a recommended
rating decision based on the collected medical evidence data; and
displaying the recommended rating decision in the generated report.
9. The method of claim 7, further comprising: generating a recommended
disability percentage based on the collected medical evidence data;
and displaying the recommended disability percentage in the generated
report.
10. The method of claim 1, further comprising associating each
of the generated medical evidence queries with a rating code of
the disability rules collection.
11. The method of claim 1, wherein displaying the generated medical
evidence queries comprises displaying at least a portion of the
generated queries in a medical provider's exam protocol.
12. The method of claim 11, wherein displaying at least a portion
of the generated queries in a medical provider's exam protocol comprises
arranging the displayed queries according to modules.
13. The method of claim 11, wherein displaying at least a portion
of the generated queries in a medical provider's exam protocol comprises
arranging the displayed queries according to classifications in
the disability rules collection.
14. The method of claim 1, wherein displaying the generated medical
evidence queries comprises displaying at least a portion of the
generated queries in a clerk's data collection protocol.
15. The method of claim 1, wherein displaying the generated medical
evidence queries comprises displaying at least a portion of the
generated queries in a claimant questionnaire.
16. The method of claim 1, further comprising eliminating duplicate
generated medical evidence queries.
17. The method of claim 1, wherein the disability rules collection
comprises a federal law.
18. The method of claim 1, wherein the disability rules collection
comprises a court case law.
19. The method of claim 1, wherein the disability rules collection
comprises an administrative decision.
20. The method of claim 1, further comprising: separating the generated
medical evidence queries into at least a first set of queries and
a second set of queries; displaying the first set of queries in
a medical provider's exam protocol; and displaying the second set
of queries in a clerk's data collection protocol.
21. The method of claim 20, wherein the first set and the second
set of queries include a duplicate query, the method further comprising:
receiving medical evidence data for the duplicate query collected
based on the clerk's data collection protocol; and removing the
duplicate query from the medical provider's exam protocol.
22. A computer-implemented method of assisting adjudication of
a medical disability request, the method comprising: receiving from
a claimant at least one claim of a medical condition; generating
a plurality of medical evidence queries based on the at least one
claim and based on a disability rules collection; receiving medical
evidence collected according to the generated medical evidence queries;
and displaying in a rating report at least a portion of the collected
medical evidence.
23. The method of claim 22, wherein each of the generated queries
is associated with a rating code of the disability rules collection,
and wherein displaying in a rating report further comprises displaying
in the rating report rating codes associated with the displayed
medical evidence.
24. A medical disability claims benefits system comprising: a rules
mapping component adapted to organize a medical disability rules
collection into at least a first plurality of general medical evidence
queries; a knowledge library adapted to store at least the first
plurality of general medical evidence queries; a claimant-specific
query creation component adapted to select from the first plurality
of general queries a second plurality of claimant-specific medical
evidence queries based on at least one claimed medical condition
of a claimant; and a protocol creation component adapted to create
at least one data collection protocol based on the second plurality
of queries.
25. The system of claim 24, wherein the rules mapping component
is further adapted to associate each of the first plurality of queries
with a rating code of the disability rules collection.
26. The system of claim 24, wherein the first plurality of general
medical evidence queries includes a triggering query and one or
more conditional queries associated with the triggering query.
27. The system of claim 24, wherein the claimant-specific query
creation component is adapted to eliminate duplicate queries from
the second plurality of claimant-specific medical evidence queries.
28. The system of claim 24, further comprising a report creation
component adapted to receive medical evidence collected according
to the at least one data collection protocol, and to display at
least a portion of the received medical evidence.
29. The system of claim 24, further comprising a claimant database
adapted to store medical evidence collected according to the at
least one data collection protocol.
Insurance Description
REFERENCE TO RELATED APPLICATIONS
[0001] The present application claims priority benefit under 35
U.S.C. .sctn. 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, both titled "METHOD OF AUTOMATED PROCESSING
OF MEDICAL DATA FOR INSURANCE AND DISABILITY DETERMINATIONS."
BACKGROUND OF THE INVENTION
[0002] 1. Field of the Invention
[0003] 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.
[0004] 2. Description of the Related Art
[0005] 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.
[0006] 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.
[0007] 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.
[0008] 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.
[0009] 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.
[0010] 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.
[0011] 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
[0012] One aspect of the invention relates to a method of assisting
the collection of medical evidence for the adjudication of a medical
insurance or disability request. One or more claims of medical conditions
are received from a claimant. Based on the received claims and based
on a rules collection, a plurality of claimant-specific medical
evidence queries are generated. A plurality of instructions are
generated based on the medical evidence queries. The instructions
are then used to collect the required medical evidence from physical
exams, laboratory tests, medical records or claimant questionnaires.
[0013] Another aspect of the invention relates to a method of assisting
the adjudication of a medical insurance or disability request. One
or more claims of medical conditions are received from a claimant.
Medical evidence queries are generated based on the received claim
and based on a disability rules collection. Each query is preferably
associated with a rating code of the rules collection. Medical evidence
is then collected from the claimant according to the generated queries.
A rating report that displays the collected medical evidence is
created to assist rating personnel in making a rating decision.
The rating report also preferably displays the rating codes associated
with the displayed medical evidence.
[0014] Still another embodiment relates to a medical disability
claims benefits system. It includes a rules mapping component, a
knowledge library, a claimant-specific queries creation component
and a protocol creation component. The rules mapping component organizes
a medical disability rules collection into at least a first plurality
of general medical evidence queries. The knowledge library stores
the first plurality of general medical evidence queries. The claimant-specific
query creation selects from the first plurality of general queries
stored in the knowledge library a second plurality of claimant-specific
medical evidence queries based on at least one claimed medical condition
of a claimant. The protocol creation component creates at least
one data collection protocol based on the second plurality of queries.
The system can also include a report creation component, which receives
medical evidence collected according to the at least one data collection
protocol, and displays at least a portion of the received medical
evidence. These components can be implemented in computer instructions.
They can be combined or separated into fewer or more components.
[0015] 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
[0016] FIG. 1 illustrates the general overview of one embodiment
of a disability benefits claims system.
[0017] FIG. 2 illustrates one embodiment of an arrangement of modules
and sub-modules.
[0018] FIG. 3 illustrates one embodiment of an arrangement of categories
and sub-categories.
[0019] FIG. 4 illustrates one embodiment of a process of organizing
rules collection into a knowledge library.
[0020] FIG. 5 illustrates one embodiment of a process of generating
claimant-specific medical evidence queries.
[0021] FIG. 6 illustrates one embodiment of a data entry form for
claimed medical conditions.
[0022] FIGS. 7A-7D illustrate one embodiment of a medical provider's
exam protocol.
[0023] FIGS. 8A-8E illustrate one embodiment of a claimant questionnaire.
[0024] FIGS. 9A-9B illustrate one embodiment of a narrative medical
report.
[0025] FIG. 10 illustrates one embodiment of a diagnostic code
summary medical report.
[0026] FIGS. 11A-11H illustrate one embodiment of a rating report.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT
[0027] 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.
[0028] Overview of Disability Benefits Claims System
[0029] FIG. 1 illustrates the general overview of one embodiment
of a disability benefits claims system 100. The rules collection
112 for the insurance or disability program and pertinent medical
knowledge 114 are organized by a FID mapping component 116 into
a knowledge library 118. Based on the claimed medical conditions
120 from a claimant and based on the rules collection or medical
knowledge stored in the knowledge library 118, the claimant-specific
query creation module 122 creates claimant-specific medical evidence
queries.
[0030] The queries are then separated into medical record queries
124 for medical records, and exam queries 126 for physical exams
and laboratory tests. The medical record queries 124 for medical
records are used by the clerk's protocol creation component 134
to create a clerk's data collection protocol to collect the required
data from medical records. The exam queries 126 for exams and tests
are used by the medical provider's exam protocol creation component
136 to create a medical provider's data collection protocol to assist
a physician, nurse or technician in conducting physical exams or
laboratory tests. The component 136 may also use the exam queries
126 to create a claimant's questionnaire to be answered by the claimant.
The medical report creation component 142 uses the medical evidence
collected from exams, tests, claimant questionnaire and medical
records to create a medical report. The rating report creation component
152 creates a rating report to assist rating personnel in adjudicating
the claims. The collected medical evidence can be stored in a claimant
database 160.
[0031] Organizing Rules Collection into Knowledge Library
[0032] Still referring to FIG. 1, component 112 represents the
rules collection for the insurance or disability program, typically
embodied in rating books, legislation, administrative decisions
and case law. Component 114 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 a FID mapping component 116
into FIDs and stored in a knowledge library component 118.
[0033] 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".
[0034] 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 FPD 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, claimant questionnaire, clerk's
data collection protocol, medical report or rating report.
[0035] 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.
[0036] The FID mapping component 116 organizes the rules collection
into a plurality of FIDs. For example, for a rating code that identifies
diabetes in a V.A. rules collection, the component 116 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."
[0037] Arrangement of Modules and Sub-modules, Categories and Sub-categories
[0038] FIG. 2 illustrates one embodiment of a disability benefits
claims systems 100 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.
[0039] As shown in FIG. 2, each sub-disease system is mapped to
one or more modules of the disability benefits claims system 100.
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.
[0040] 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.
[0041] 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 the knowledge library 118 stores
the FIDs for each sub-module.
[0042] 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.
[0043] Referring to FIG. 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.
[0044] FIG. 4 illustrates one embodiment of a process of organizing
rules collection into FIDs. From a start block 410, the process
proceeds to a block 420 to identify rating codes from the rating
books for the disability or insurance program. The process then
proceeds to a block 430 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."
[0045] The process then proceeds to a block 440 to group the data
fields by category. In another embodiment, data fields are grouped
by sub-category. The process proceeds to a block 450, 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 a block 460 to store the FIDs
in a knowledge library component 118. The process terminates at
an end block 470.
[0046] Generating Claimant-specific Medical Evidence Queries
[0047] In FIG. 1, the claimant-specific query creation module 122
receives the claimed medical conditions 120 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 the knowledge library 118. FIG. 5 illustrates one embodiment
of the query-creation process.
[0048] Referring to FIG. 5, the process starts from a start block
510 and proceeds to a block 520, where the query creation component
122 receives one or more claims of medical conditions from the claimant.
In one embodiment, the component 122 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 the knowledge library 118 for the particular insurance or disability
program and displayed as a reminder to the medical provider.
[0049] Referring back to FIG. 5, at a block 530, the component
122 identifies the related modules based on the received claims.
For example, if the claimed condition is "loss of eyesight,"
the component 122 may identify a "physical exam" module
and a "neurological exam" module. The relationships of
medical conditions and related modules are stored in the knowledge
library 118. The component 122 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, the component 122 identifies the related sub-modules, the
related categories, or the related sub-categories. In another embodiment,
the component 122 directly identifies the related FIDs stored in
the knowledge library 118 based on the received claims.
[0050] At a block 540 of FIG. 5, the component 122 selects those
FIDs in the knowledge library 118 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. In one embodiment,
the component 122 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.
[0051] From the block 540, the process proceeds to a block 550,
where the component 122 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 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.
[0052] If all generated queries may be obtained from medical records,
then the process proceeds to a block 570. Otherwise the process
proceeds to a block 560, where the component 122 generates a set
of claimant-specific queries to be satisfied from physical exams,
claimant questionnaires, or laboratory tests. At the block 570,
the component 122 generates a set of queries whose results can be
obtained from existing medical records. The claimant-specific queries
generated at the block 540 are thus separated into two sets of queries.
In another embodiment, the queries generated at the block 540 are
separated into three sets: one set of queries to be satisfied from
physical exams and claimant questionnaires, another set to be satisfied
from laboratory tests, and a third set to be satisfied from medical
records.
[0053] Referring back to the blocks 530 and 540 of FIG. 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.
The component 122 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.
[0054] Each module is associated with a priority number stored
in the knowledge library 118. 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 the knowledge library 118.
[0055] 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 the system 100. The human operator can also change
the order of generated claimant-specific queries determined by the
priority numbers.
[0056] The component 122 also checks special rules stored in the
knowledge library 118 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 the
knowledge library 118. The stored Deluca special rules can be associated
with FIDs, categories or modules stored in the knowledge library
118. When the generated claimant-specific queries include a FID
associated with a special rule, the special rule is retrieved from
the knowledge library 118 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.
[0057] Creating Medical Provider's and Clerk's Data Collection
Protocols
[0058] Referring back to FIG. 1, based on the generated set of
claimant-specific queries for exams, the medical provider's protocol
creation component 136 creates a medical provider's data collection
protocol, also called a physician's exam protocol. The component
136 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's protocol creation component 134
creates a clerk's data collection protocol.
[0059] 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 in FIGS. 7A-7D, the queries are grouped
by category and sub-category. For example, the category "PHYSICAL
EXAMINATION" shown in FIG. 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.
[0060] 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.
[0061] The medical evidence collected by the medical provider is
then stored into the disability claims benefits system 100. 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.sub.--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.
[0062] To replace or to supplement the physician's exam protocol,
the component 136 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.
[0063] 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 the knowledge library 118 that are associated with stored
general medical evidence queries. In one embodiment, the disability
benefits claims system is connected to an electronic data storage
that stores existing medical records, for example the claimant database
160. The system then automatically searches the storage and collects
required medical evidence from the storage. 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.
[0064] Follow-up Queries based on Collected Medical Evidence
[0065] The query creation component 122 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 the rules collection 112 or according to medical knowledge
114. 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.
[0066] In one embodiment, the FID of a triggering query stored
in the knowledge library 118 includes a list of the FIDs of the
conditional queries. In another embodiment, each query is stored
as an object in the knowledge library 118, 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, the knowledge library 118
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-specific query creation component
122 generates a triggering query as a claimant-specific query, the
conditional queries for the triggering query are preferably also
generated as claimant-specific queries. The protocol creation components
134 and 136 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."
[0067] 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, the system 100 compares the entered medical
evidence with the triggering query's triggering rule stored in the
knowledge library 118, 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.
[0068] Creating Medical Report
[0069] Referring back to FIG. 1, after medical evidence is collected
from physical examinations, laboratory tests, medical records and
claimant questionnaire, the collected medical evidence is used by
a medical report creation component 142 to create a medical report.
FIGS. 9A-9B and FIG. 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.
[0070] 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.
[0071] 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 with
FIGS. 11A-11H.
[0072] 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.
[0073] Creating Rating Report
[0074] Referring back to FIG. 1, the rating report creation component
152 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.
[0075] In one embodiment, the rating report creation component
152 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 in FIG. 11C, for the rating code "5259", the
component 152 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.
[0076] The disclosed disability claims benefits system 100 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.
[0077] 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. |