DETAILED ACTION
Notice to Applicant
The present application, filed on or after March 16, 2013, is being examined under the first inventor to file provisions of the AIA .
This communication is in response to the amendment filed on 2/19/25. Claims 1-18 have been canceled. Claims 19-39 are pending.
The IDS filed 5/22/25 has been considered by the examiner.
Claim Rejections - 35 USC § 101
35 U.S.C. 101 reads as follows:
Whoever invents or discovers any new and useful process, machine, manufacture, or composition of matter, or any new and useful improvement thereof, may obtain a patent therefor, subject to the conditions and requirements of this title.
Claims 19-39 are rejected under 35 U.S.C. 101 because the claimed invention is directed to a judicial exception (i.e, a law of nature, a natural phenomenon, or an abstract idea) without significantly more.
35 USC 101 enumerates four categories of subject matter that Congress deemed to be appropriate subject matter for a patent: processes, machines, manufactures and compositions of matter. As explained by the courts, these “four categories together describe the exclusive reach of patentable subject matter. If a claim covers material not found in any of the four statutory categories, that claim falls outside the plainly expressed scope of Section 101 even if the subject matter is otherwise new and useful.” In re Nuijten, 500 F.3d 1346, 1354, 84 USPQ2d 1495, 1500 (Fed. Cir. 2007). Step 1 of the eligibility analysis asks: Is the claim to a process, machine, manufacture or composition of matter? Applicant’s claims fall within at least one of the four categories of patent eligible subject matter because claims 19-30 are drawn to a system; and claims 31-38 are drawn to a method for determining healthcare vitality.
Determining that a claim falls within one of the four enumerated categories of patentable subject matter recited in 35 USC 101 (i.e., process, machine, manufacture, or composition of matter) in Step 1 does not complete the eligibility analysis. Claims drawn only to an abstract idea, a natural phenomenon, and laws of nature are not eligible for patent protection. As described in MPEP 2106, subsection III, Step 2A of the Office’s eligibility analysis is the first part of the Alice/Mayo test, i.e., the Supreme Court’s “framework for distinguishing patents that claim laws of nature, natural phenomena, and abstract ideas from those that claim patent-eligible applications of those concepts.” Alice Corp. Pty. Ltd. v. CLS Bank Int'l,134 S. Ct. 2347, 2355, 110 USPQ2d 1976, 1981 (2014) (citing Mayo, 566 U.S. at 77-78, 101 USPQ2d at 1967-68).
In 2019, the United States Patent and Trademark Office (USPTO) prepared revised guidance (2019 Revised Patent Subject Matter Eligibility Guidance) for use by USPTO personnel in evaluating subject matter eligibility. The framework for this revised guidance, which sets forth the procedures for determining whether a patent claim or patent application claim is directed to a judicial exception (laws of nature, natural phenomena, and abstract ideas), is described in MPEP sections 2106.03 and 2106.04.
As explained in MPEP 2106.04(a)(2), the 2019 Revised Patent Subject Matter Eligibility Guidance explains that abstract ideas can be grouped as, e.g., mathematical concepts, certain methods of organizing human activity, and mental processes. Moreover, this guidance explains that a patent claim or patent application claim that recites a judicial exception is not ‘‘directed to’’ the judicial exception if the judicial exception is integrated into a practical application of the judicial exception. A claim that recites a judicial exception, but is not integrated into a practical application, is directed to the judicial exception under Step 2A and must then be evaluated under Step 2B (inventive concept) to determine the subject matter eligibility of the claim.
Step 2A asks: Does the claim recite a law of nature, a natural phenomenon (product of nature) or an abstract idea? (Prong One) If so, is the judicial exception integrated into a practical application of the judicial exception? (Prong Two) A claim recites a judicial exception when a law of nature, a natural phenomenon, or an abstract idea is set forth or described in the claim. While the terms “set forth” and “describe” are thus both equated with “recite”, their different language is intended to indicate that there are different ways in which an exception can be recited in a claim. For instance, the claims in Diehr set forth a mathematical equation in the repetitively calculating step, while the claims in Mayo set forth laws of nature in the wherein clause, meaning that the claims in those cases contained discrete claim language that was identifiable as a judicial exception. The claims in Alice Corp., however, described the concept of intermediated settlement without ever explicitly using the words “intermediated” or “settlement.” A claim that integrates a judicial exception into a practical application will apply, rely on, or use the judicial exception in a manner that imposes a meaningful limit on the judicial exception, such that the claim is more than a drafting effort designed to monopolize the judicial exception.
In the instant case, claims 19-39 recite(s) systems for certain methods of organizing human activities, which is subject matter that falls within the enumerated groupings of abstract ideas described in MPEP 2106.04 (2019 Revised Patent Subject Matter Eligibility Guidance) Certain methods of organizing human activities includes fundamental economic practices, like insurance; commercial interactions (i.e. legal obligations, marketing or sales activities or behaviors, and business relations). Organizing human activity also encompasses managing personal behavior or relationships or interactions between people (including social activities, teaching, and following rules or instructions.) The recited method and system are drawn to determining vitality scores as a basis of comparison for healthcare providers. (i.e. managing personal behavior or relationships or interactions between people)
In particular, Claims 19 and 31 recite a system and method for:
de-identify at least a portion of the provider data received from the plurality of healthcare provider devices based at least in part on a known data format;
match at least a portion of the provider data having been de-identified to encounter data to create a set of matched de-identified data, the encounter data being defined by one or more encounters, each of the one or more encounters corresponding to other medical services performed by the healthcare provider or a third-party provider;
extract, from the matched de-identified data, at least one set of coded information according to a predetermined data format of the set of provider data to categorize the matched de-identified data based at least in part upon the determined at least one set of coded information;
determine a vitality composite score based at least in part upon the at least one set of coded information, the vitality composite score comprising at least one of a velocity index, a value index, a variety index, or a volatility index;
selectively normalize at least one set of coded information in association with the vitality composite score to form normalized provider data, the normalized provider data representative of provider data grouped on a national, regional, or peer basis; and compare normalized provider data for a selected healthcare provider to normalized provider data for one or more healthcare providers to create comparison data.
This judicial exception is not integrated into a practical application because the claim language does not recite any improvements to the functioning of a computer, or to any other technology or technical field (See MPEP 2106.04(d)(1); see also MPEP 2106.05(a)(I-II)). Moreover, the claims do not integrate the judicial exception into a practical application because the claimed invention does not: apply the judicial exception with, or by use of, a particular machine (see MPEP 2106.05(b)); effect a transformation or reduction of a particular article to a different state or thing (see MPEP 2106.05(c)); or apply or using the judicial exception in some other meaningful way beyond generally linking the use of the judicial exception to a particular technological environment see MPEP 2106.05(e). (Considerations for integration into a practical application in Step 2A, prong two and for recitation of significantly more than the judicial exception in Step 2B)
While abstract ideas, natural phenomena, and laws of nature are not eligible for patenting by themselves, claims that integrate these exceptions into an inventive concept are thereby transformed into patent-eligible inventions. Alice Corp. Pty. Ltd. v. CLS Bank Int'l, 134 S. Ct. 2347, 2354, 110 USPQ2d 1976, 1981 (2014) (citing Mayo Collaborative Servs. v. Prometheus Labs., Inc., 566 U.S. 66, 71-72, 101 USPQ2d 1961, 1966 (2012)). Thus, the second part of the Alice/Mayo test is often referred to as a search for an inventive concept. Id. An “inventive concept” is furnished by an element or combination of elements that is recited in the claim in addition to (beyond) the judicial exception, and is sufficient to ensure that the claim as a whole amounts to significantly more than the judicial exception itself. Alice Corp., 134 S. Ct. at 2355, 110 USPQ2d at 1981 (citing Mayo, 566 U.S. at 72-73, 101 USPQ2d at 1966). Although the courts often evaluate considerations such as the conventionality of an additional element in the eligibility analysis, the search for an inventive concept should not be confused with a novelty or non-obviousness determination. See Mayo, 566 U.S. at 91, 101 USPQ2d at 1973 (rejecting “the Government’s invitation to substitute Sections 102, 103, and 112 inquiries for the better established inquiry under Section 101”). As made clear by the courts, the “‘novelty’ of any element or steps in a process, or even of the process itself, is of no relevance in determining whether the subject matter of a claim falls within the Section 101 categories of possibly patentable subject matter.” Intellectual Ventures I v. Symantec Corp.,838 F.3d 1307, 1315, 120 USPQ2d 1353, 1358 (Fed. Cir. 2016) (quoting Diamond v. Diehr, 450 U.S. at 188–89, 209 USPQ at 9).
As described in MPEP 2106.05, Step 2B of the Office’s eligibility analysis is the second part of the Alice/Mayo test, i.e., the Supreme Court’s “framework for distinguishing patents that claim laws of nature, natural phenomena, and abstract ideas from those that claim patent-eligible applications of those concepts.” Alice Corp. Pty. Ltd. v. CLS Bank Int'l, 573 U.S. _, 134 S. Ct. 2347, 2355, 110 USPQ2d 1976, 1981 (2014) (citing Mayo, 566 U.S. 66, 101 USPQ2d 1961 (2012)). Step 2B asks: Does the claim recite additional elements that amount to significantly more than the judicial exception? The claim(s) does/do not include additional elements that are sufficient to amount to significantly more than the judicial exception.
Claims 19 and 31 further recite: receive provider data from the plurality of healthcare provider devices. The additional steps amount to insignificant extra-solution activity to the judicial exception (see MPEP 2106.05(g)). Examples of insignificant extra-solution activity include mere data gathering, selecting a particular data source or type of data to be manipulated, and insignificant application. In the instant case the additional steps amount to necessary data gathering and outputting, (i.e., all uses of the recited judicial exception require such data gathering or data output). See Mayo, 566 U.S. at 79, 101 USPQ2d at 1968; OIP Techs., Inc. v. Amazon.com, Inc., 788 F.3d 1359, 1363, 115 USPQ2d 1090, 1092-93 (Fed. Cir. 2015) (presenting offers and gathering statistics amounted to mere data gathering)
Claim 19 recites additional limitation(s), a network; a plurality of healthcare provider devices; and a server. Claim 31 recites a server; a healthcare provider device and a network. Claims 21 and 34 also recite a display unit of the user device. These additional components are generic components performing functions that are well-understood, routine and conventional activities and amount to no more than implementing the abstract idea with a computerized system.
The generic nature of the computer system used to carryout steps of the recited method is underscored by the system description in the instant application, which discloses: ““Each of the microprocessor 122, the storage unit 124, the communications unit 126, and the display unit 128 is configured to respectively correspond to the previously described microprocessor 102, the storage unit 104, the communications unit 106, and the display unit 108 without departing from the spirit and the scope of the present disclosure.” (par. 107)
The application explains: “the end user electronic device 100 is at least one of a desktop computer, a laptop computer, a smart phone, or any other electronic device capable of executing instructions. The microprocessor 102 is configured to take the form of a generic hardware processor, a special-purpose hardware processor, or a combination thereof. In embodiments having a generic hardware processor (e.g., as a central processing unit (CPU) available from manufacturers such as Intel and AMD), the generic hardware processor is configured to be converted to a special-purpose processor by means of being programmed to execute and/or by executing a particular algorithm in the manner discussed herein for providing one or more specific operations or results” (see par. 105)
Additionally, the disclosure explains: “one or more server 120 is configured to be located at a fixed location and comprises desktop computer or server computer configured to receive input from an end user regarding information discussed above. At least one server 120 may be configured to operate as a standalone server, as a distributed server, as a cloud service-based server, or any other configuration capable of executing or otherwise implementing at least one action. One or more server 120 may have stored therein or otherwise have access to an application or information storage system including information or data executable thereon or therewith to perform one or more operations described herein (including determining one or more values, parameters, data sets, data operations, or any other operation, process, or step consistent with the present disclosure). In various embodiments, the server 120 is configured to operate remotely, and is additionally configured to obtain or otherwise operate upon one or more instructions stored physically remote from the server 120 (e.g., via client-server communications and/or cloud-based computing)” (par. 108)
Such language underscores that the applicant's perceived invention/ novelty focuses on the computerized implementation of the abstract idea, not the underlying structure of generic system components.
Furthermore, the courts have recognized certain computer functions as well‐understood, routine, and conventional functions when they are claimed in a merely generic manner (e.g., at a high level of generality) or as insignificant extra-solution activity (See MPEP 2106.05 (d) (II)). Among these are the following features, which are recited in claim 19 and claim 31:
- Receiving or transmitting data over a network, e.g., using the Internet to gather data, Symantec, 838 F.3d at 1321, 120 USPQ2d at 1362 (utilizing an intermediary computer to forward information); TLI Communications LLC v. AV Auto. LLC, 823 F.3d 607, 610, 118 USPQ2d 1744, 1745 (Fed. Cir. 2016) (using a telephone for image transmission); OIP Techs., Inc., v. Amazon.com, Inc., 788 F.3d 1359, 1363, 115 USPQ2d 1090, 1093 (Fed. Cir. 2015) (sending messages over a network); buySAFE, Inc. v. Google, Inc., 765 F.3d 1350, 1355, 112 USPQ2d 1093, 1096 (Fed. Cir. 2014) (computer receives and sends information over a network); but see DDR Holdings, LLC v. Hotels.com, L.P., 773 F.3d 1245, 1258, 113 USPQ2d 1097, 1106 (Fed. Cir. 2014) ("Unlike the claims in Ultramercial, the claims at issue here specify how interactions with the Internet are manipulated to yield a desired result‐‐a result that overrides the routine and conventional sequence of events ordinarily triggered by the click of a hyperlink." (emphasis added));
- Performing repetitive calculations, Flook, 437 U.S. at 594, 198 USPQ2d at 199 (recomputing or readjusting alarm limit values); Bancorp Services v. Sun Life, 687 F.3d 1266, 1278, 103 USPQ2d 1425, 1433 (Fed. Cir. 2012) ("The computer required by some of Bancorp’s claims is employed only for its most basic function, the performance of repetitive calculations, and as such does not impose meaningful limits on the scope of those claims.");
- Storing and retrieving information in memory, Versata Dev. Group, Inc. v. SAP Am., Inc., 793 F.3d 1306, 1334, 115 USPQ2d 1681, 1701 (Fed. Cir. 2015); OIP Techs., 788 F.3d at 1363, 115 USPQ2d at 1092-93;
- Electronically scanning or extracting data from a physical document, Content Extraction and Transmission, LLC v. Wells Fargo Bank, 776 F.3d 1343, 1348, 113 USPQ2d 1354, 1358 (Fed. Cir. 2014) (optical character recognition); and
Because Applicant’s claimed invention recites a judicial exception that is not integrated into a practical application and does not include additional elements that are sufficient to amount to significantly more than the judicial exception itself, the claimed invention is not patent eligible.
Claims 20-30 are dependent from Claim 19 and include(s) all the limitations of claim(s) 19. However, the additional limitations of the claims 20-30 fail to recite significantly more than the abstract idea. More specifically, the additional limitations further define the abstract idea with additional steps or details regarding data types; or additional steps which amount to insignificant extra solution activities. Therefore, claim(s) 20-30 are also rejected under 35 U.S.C. 101 as being directed to non-statutory subject matter.
Claims 32-39 are dependent from Claim 31 and include(s) all the limitations of claim(s) 31. However, the additional limitations of the claims 32-39 fail to recite significantly more than the abstract idea. More specifically, the additional limitations further define the abstract idea with additional steps or details regarding data types; or additional steps which amount to insignificant extra solution activities. Therefore, claim(s) 32-39 are also rejected under 35 U.S.C. 101 as being directed to non-statutory subject matter.
Claim Rejections - 35 USC § 103
In the event the determination of the status of the application as subject to AIA 35 U.S.C. 102 and 103 (or as subject to pre-AIA 35 U.S.C. 102 and 103) is incorrect, any correction of the statutory basis (i.e., changing from AIA to pre-AIA ) for the rejection will not be considered a new ground of rejection if the prior art relied upon, and the rationale supporting the rejection, would be the same under either status.
The following is a quotation of 35 U.S.C. 103 which forms the basis for all obviousness rejections set forth in this Office action:
A patent for a claimed invention may not be obtained, notwithstanding that the claimed invention is not identically disclosed as set forth in section 102, if the differences between the claimed invention and the prior art are such that the claimed invention as a whole would have been obvious before the effective filing date of the claimed invention to a person having ordinary skill in the art to which the claimed invention pertains. Patentability shall not be negated by the manner in which the invention was made.
Claim(s) 19-31 is/are rejected under 35 U.S.C. 103 as being unpatentable over Edgar (US-20150317337-A1) in view of Rogers (US-8898798-B2),
Claim 19 Edgar discloses system for determining healthcare vitality, comprising:
a network (a wired local area network (LAN), wireless LAN, wide area network (WAN), etc. [0050]);
a plurality of healthcare provider devices, each healthcare provider device of the plurality of healthcare provider devices including a communication section and being communicatively coupled to the network via the communication section, (par. 0043-0045; )
wherein each healthcare provider device of the plurality of healthcare provider devices is associated with a healthcare provider and configured to transmit provider data via the network (PACS 208 can also include a display device and/or viewing workstation to enable a healthcare practitioner or provider to communicate with PACS 208. [0057], the provider data comprising information regarding a medical service performed by the healthcare provider ([0085]-[0086]- Electronic data interchange (EDI) provides claim and remittance processing between a provider and a payer; [0089] EDI services facilitate data exchange and processing to map patient services with claims, payer information, denials, and associated causes and recommendation)
a server having a storage having a communication unit, the server communicatively coupled to the network via the communication unit and (par. 43-45; par. 61-62; par. 69-70; healthcare institutions provide enhanced control and safe guarding of the exchange and storage of sensitive patient PHI and employee information between diverse locations [0034] , data center 212 is managed by an application server provider (ASP) and is located in a centralized location that can be accessed by a plurality of systems and facilities [0061]):
receive provider data from the plurality of healthcare provider devices; (healthcare institutions provide enhanced control and safe guarding of the exchange and storage of sensitive patient PHI and employee information between diverse locations [0034] , data center 212 is managed by an application server provider (ASP) and is located in a centralized location that can be accessed by a plurality of systems and facilities [0061]):
determine a vitality composite score based at least in part upon the at least one set of coded information (At block 1830, pattern(s) are scored and processed based on a comparison with statistical model meta data. For example, pattern(s)/trend(s) are scored with respect to statistical model meta data such as a p value, odds ratio, relative risk, business metric (e.g., revenue, cost, etc.), etc. [0133] data can include Healthcare EDI payment transactions…machine to machine status data with variables (e.g., variables that in Healthcare EDI payment transactions include denial reason codes, denial group codes, denial remark codes [0131] Metrics 520 can be scored by total amount (e.g., sum), average percent, unexpectedness, etc. [0094]), the vitality composite score comprising at least one of a velocity index, a value index, a variety index, or a volatility index; (Value index; [0086]- An opportunity benchmark measures an amount of value to an enterprise if a problem can be addressed. An opportunity benchmark equals an opportunity cost…For a denial, an opportunity benchmark equals a denied cost plus a cost of labor to fix; [0101]: Included with the example view 1300 of FIG. 13 is a visualization of an “opportunity benchmark” represented by both an estimated cost of rework and an impact to working capital to an associated organization);
selectively normalize at least one set of coded information in association with the vitality composite score to form normalized provider data, the normalized provider data representative of provider data grouped on a national, regional, or peer basis; and (Upon review, the data in the list shows an issue with balance billing to Medicaid which can be corrected with an adjustment to claim logic to include correct carrier codes, a problem being seen for the first time with this payer per the denials data in this example [0103]; the semantic results are displayed for user review and action. [0144])
compare normalized provider data for a selected healthcare provider to normalized provider data for one or more healthcare providers to create comparison data. (The example of FIG. 14 shows a list of recent encounters ranked by dollar value displayed via a denials scenario interface [0103])
Edgar does not expressly disclose a system configured to:
de-identify at least a portion of the provider data received from the plurality of healthcare provider devices based at least in part on a known data format;
match at least a portion of the provider data having been de-identified to encounter data to create a set of matched de-identified data, the encounter data being defined by one or more encounters, each of the one or more encounters corresponding to other medical services performed by the healthcare provider or a third-party provider;
extract, from the matched de-identified data, at least one set of coded information according to a predetermined data format of the set of provider data to categorize the matched de-identified data based at least in part upon the determined at least one set of coded information.
Rogers teaches a system including components configured to:
de-identify at least a portion of the provider data received from the plurality of healthcare provider devices based at least in part on a known data format; (Col. 2 lines 39-44: when additional information needs to be meta-tagged for a specific patient or additional data needs to be added to a specific patient, reintegration may be employed; potentially followed by a Subsequent deidentification (decoupling of the patient identifying information from the clinical data) step.)
match at least a portion of the provider data having been de-identified to encounter data to create a set of matched de-identified data, the encounter data being defined by one or more encounters, (Identification of duplicate patients is done by comparing patient identification, as received by parser 418, from the source 122, to known patients with the MINE 112 and a determination of a thresh old number of matches of the patient’s received identification. [Col. 12 lines 15-20], each of the one or more encounters corresponding to other medical services performed by the healthcare provider or a third-party provider; (col. 2, lines 32-35; col. 25, lines 62-col. 26, lines 7-matched data includes clinical event data information regarding procedures/treatments rendered by a provider to a patient)
extract, from the matched de-identified data, at least one set of coded information according to a predetermined data format of the set of provider data to categorize the matched de-identified data based at least in part upon the determined at least one set of coded information. (a patient whose social security matches a known patient record within the MINE 112 may be determined to be the same patient or a patient whose last name partially matches another last name and has other matching information, [Col. 12 lines 20-24] Healthcare organizations can use MINE 112 as their data foundation to aggregate and unlock the full potential of their coded and unstructured data from across multiple sites. [Col. 20 lines 48-50] Using advanced natural language processing (NLP) technology to understand the intent behind the queries typed by the user, MINE is able to return the most relevant results to that query. [Col. 4 lines 47-50]).
At the time of the effective filing date, it would have been obvious to one of ordinary skill in the art to modify the system of Edgar with the teaching of Rogers to perform a de-identification operation on at least a portion of the received set of provider data, perform a matching operation on the at least a portion of the received set of provider data and process the matched de-identified data to extract at least one set of coded information according to a predetermined data format of the set of provider data, with the motivation of improving the quality and security of data provided, and to manage medical information in a manner that is beneficial, reliable, portable, flexible, and efficiently usable to those in the medical field, including patients [Col. 2 lines 1-7]
Claim 20 Edgar teaches the system of Claim 19, wherein the server is further configured to associate one or more of the categorized matched de-identified data with the plurality of healthcare providers. (Certain aspects interrelate people, processes, and technology both at a healthcare provider and a payer to facilitate action on denials. [0084] one or more denial categories of interest 720 can be selected with a few clicks of a mouse and/or other indication 725 of category information 720 (e.g., denied dollars, denied claim count, etc.) [0098])
Claim 21 Edgar teaches the system of Claim 19, further comprising: a user device including a communication section and a display unit, the user device communicatively coupled to the network via the communication section and configured to provide a representation of the information relating to the normalized provider data via the display unit. (The display can be in the form of a network interface or graphic user interface (GUI) to exchange data, instructions, or illustrations on a computing device via communication inter face [0045] Metrics 520 can be measured by one or more criteria Such as denial count, opportunity cost, percentage of denied charges, rework cost, etc. [0094] an example interface 700 provides overview one or more denial categories of interest 720 can be selected with a few clicks of a mouse and/or other pointing/cursor control device selecting and/or hovering over a point on a graph and/or other indication 725 of category information 720 (e.g., denied dollars, denied claim count, etc.). [0098])
Claim 22 Edgar discloses the system of Claim 21, wherein the user device is configured to provide a user with access to information relating to normalized provider data for the selected healthcare provider. (Upon review, the data in the list shows an issue with balance billing to Medicaid which can be corrected with an adjustment to claim logic to include correct carrier codes, a problem being seen for the first time with this payer per the denials data in this example [0103] the semantic results are displayed for user review and action. [0144])
Claim 23 Edgar teaches the system of Claim 21, wherein the user device is further configured to display the normalized provider data for a plurality of healthcare providers via the display unit. (Upon review, the data in the list shows an issue with balance billing to Medicaid which can be corrected with an adjustment to claim logic to include correct carrier codes, a problem being seen for the first time with this payer per the denials data in this example [0103] the semantic results are displayed for user review and action. [0144])
Claim 24 Edgar teaches the system of Claim 21, wherein the user device is configured to provide a user with access to information relating to the normalized provider data for the selected healthcare provider via a secure, encrypted, website URL (SHTTP), as made available by the server via the network. (Patient/provider association information may include a provider identifier, a patient identifier, an encrypted key, and one or more override security categories. Memory 140 can be structured according to provider, patient, patient/provider association, and document. [0049]);
Claim 25 Edgar discloses the system of Claim 21, wherein the server is further configured to assign each user of the user device a user type, the user type being associated with the user's level of access to data stored on the server. (Certain examples provide one or more dashboards for specific sets of patients or sets of operational data. Dashboard(s) can be based on condition, role, and/or other criteria to indicate variation(s) from a desired practice, [0039])
Claim 26. Edgar discloses the system of Claim 19, wherein the server is further configured to categorize the at least a portion of the matched de-identified data to at least one category which is non-coded with respect to a data format of the provider data. (Using the example dashboard 600, specific categories can be reviewed to assess most significant areas of opportunity by dollar and count, with an added ability to filter down to areas that a user wishes to better understand. [0097] the interface 1300 provides a representation of actionable opportunity by category (e.g., by denial category or type descriptor including coding, eligibility, miscellaneous, non-covered, prior authorization, family filing, etc.) By selecting and/or otherwise positioning a cursor over a denial scenario category 1310 (e.g., a denial scenario code CO22.MA92 related to eligibility), [0101] Certain aspects interrelate people, processes, and technology both at a healthcare provider and a payer to facilitate action on denials. [0084]);
Claim 27 Edgar discloses the system of Claim 19, wherein the provider data includes 837 claim files or 835 remittance files. (par. 0079-reating an ANSI X12N claim transaction that includes all information in correct format; and submitting a claim transaction to a correct payer and within timely filing limits from the patient accounting accounts receivable system for each invoice and related services. Remittance data is received from the payer that includes payment and adjustment or denial amounts. The remittance data is posted to the correct invoice in accounts receivable. Denials for services not paid are handled, which includes understanding denial reasons, potential cause, etc.; par. 0085-Electronic data interchange (EDI) provides claim and remittance processing between a provider and a payer. A defect can be introduced at a variety of points in the process between provider and payer; [0118]- meaningful data includes healthcare EDI payment transactions (e.g., X12 documents, ANSI 837 claims, ANSI 835 remits, ANSI 277CA rejections, etc.), server logfiles, equipment fault data, machine alarm data, machine to machine status data, etc)
Claim 28 Edgar discloses the system of Claim 19, wherein the encounter data includes at least one or more of claims data, encounter status data, remit data, remit service fine data, or remit adjustment data. (par. 0079-reating an ANSI X12N claim transaction that includes all information in correct format; and submitting a claim transaction to a correct payer and within timely filing limits from the patient accounting accounts receivable system for each invoice and related services. Remittance data is received from the payer that includes payment and adjustment or denial amounts. The remittance data is posted to the correct invoice in accounts receivable. Denials for services not paid are handled, which includes understanding denial reasons, potential cause, etc.; par. 0085-Electronic data interchange (EDI) provides claim and remittance processing between a provider and a payer. A defect can be introduced at a variety of points in the process between provider and payer)
Claim 29. Edgar discloses the system of Claim 19, wherein the velocity index comprises a measurement of how quickly the healthcare provider is expected to collect reimbursement for performance of medical services, the value index comprises a measurement of a financial value of reimbursement to the healthcare provider, the variety index comprises a measurement of a diversification of cashflow from a plurality of payers, and the volatility index comprises a measurement risk associated with denials flowing to the healthcare provider. (Value index; [0086]- An opportunity benchmark measures an amount of value to an enterprise if a problem can be addressed. An opportunity benchmark equals an opportunity cost…For a denial, an opportunity benchmark equals a denied cost plus a cost of labor to fix; [0101]: Included with the example view 1300 of FIG. 13 is a visualization of an “opportunity benchmark” represented by both an estimated cost of rework and an impact to working capital to an associated organization; data can include Healthcare EDI payment transactions…machine to machine status data with variables (e.g., variables that in Healthcare EDI payment transactions include denial reason codes, denial group codes, denial remark codes [0131] Metrics 520 can be scored by total amount (e.g., sum), average percent, unexpectedness, etc. [0094]));
Claim 30 Edgar discloses the system of Claim 19, wherein the normalized provider data for the one or more healthcare providers is stored in the storage of the server. (Patient/provider association information may include a provider identifier, a patient identifier, an encrypted key, and one or more override security categories. Memory 140 can be structured according to provider, patient, patient/provider association, and document. [0049])
Claim 31 Edgar discloses method for determining healthcare vitality, comprising:
receiving provider data from the plurality of healthcare provider devices; (healthcare institutions provide enhanced control and safe guarding of the exchange and storage of sensitive patient PHI and employee information between diverse locations [0034] , data center 212 is managed by an application server provider (ASP) and is located in a centralized location that can be accessed by a plurality of systems and facilities [0061]):
determining a vitality composite score based at least in part upon the at least one set of coded information (At block 1830, pattern(s) are scored and processed based on a comparison with statistical model meta data. For example, pattern(s)/trend(s) are scored with respect to statistical model meta data such as a p value, odds ratio, relative risk, business metric (e.g., revenue, cost, etc.), etc. [0133] data can include Healthcare EDI payment transactions…machine to machine status data with variables (e.g., variables that in Healthcare EDI payment transactions include denial reason codes, denial group codes, denial remark codes [0131] Metrics 520 can be scored by total amount (e.g., sum), average percent, unexpectedness, etc. [0094]), the vitality composite score comprising at least one of a velocity index, a value index, a variety index, or a volatility index; (Value index; [0086]- An opportunity benchmark measures an amount of value to an enterprise if a problem can be addressed. An opportunity benchmark equals an opportunity cost…For a denial, an opportunity benchmark equals a denied cost plus a cost of labor to fix; [0101]: Included with the example view 1300 of FIG. 13 is a visualization of an “opportunity benchmark” represented by both an estimated cost of rework and an impact to working capital to an associated organization);
selectively normalizing at least one set of coded information in association with the vitality composite score to form normalized provider data, the normalized provider data representative of provider data grouped on a national, regional, or peer basis; and (Upon review, the data in the list shows an issue with balance billing to Medicaid which can be corrected with an adjustment to claim logic to include correct carrier codes, a problem being seen for the first time with this payer per the denials data in this example [0103]; the semantic results are displayed for user review and action. [0144])
comparing normalized provider data for a selected healthcare provider to normalized provider data for one or more healthcare providers to create comparison data. (The example of FIG. 14 shows a list of recent encounters ranked by dollar value displayed via a denials scenario interface [0103])
Edgar does not expressly disclose a system configured to:
de-identifying at least a portion of the provider data received from the plurality of healthcare provider devices based at least in part on a known data format;
matching at least a portion of the provider data having been de-identified to encounter data to create a set of matched de-identified data, the encounter data being defined by one or more encounters, each of the one or more encounters corresponding to other medical services performed by the healthcare provider or a third-party provider;
extracting, from the matched de-identified data, at least one set of coded information according to a predetermined data format of the set of provider data to categorize the matched de-identified data based at least in part upon the determined at least one set of coded information.
Rogers teaches a system including components configured to:
de-identifying at least a portion of the provider data received from the plurality of healthcare provider devices based at least in part on a known data format; (Col. 2 lines 39-44: when additional information needs to be meta-tagged for a specific patient or additional data needs to be added to a specific patient, reintegration may be employed; potentially followed by a Subsequent deidentification (decoupling of the patient identifying information from the clinical data) step.)
matching at least a portion of the provider data having been de-identified to encounter data to create a set of matched de-identified data, the encounter data being defined by one or more encounters, (Identification of duplicate patients is done by comparing patient identification, as received by parser 418, from the source 122, to known patients with the MINE 112 and a determination of a thresh old number of matches of the patient’s received identification. [Col. 12 lines 15-20], each of the one or more encounters corresponding to other medical services performed by the healthcare provider or a third-party provider; (col. 2, lines 32-35; col. 25, lines 62-col. 26, lines 7-matched data includes clinical event data information regarding procedures/treatments rendered by a provider to a patient)
extracting, from the matched de-identified data, at least one set of coded information according to a predetermined data format of the set of provider data to categorize the matched de-identified data based at least in part upon the determined at least one set of coded information. (a patient whose social security matches a known patient record within the MINE 112 may be determined to be the same patient or a patient whose last name partially matches another last name and has other matching information, [Col. 12 lines 20-24] Healthcare organizations can use MINE 112 as their data foundation to aggregate and unlock the full potential of their coded and unstructured data from across multiple sites. [Col. 20 lines 48-50] Using advanced natural language processing (NLP) technology to understand the intent behind the queries typed by the user, MINE is able to return the most relevant results to that query. [Col. 4 lines 47-50]).
At the time of the effective filing date, it would have been obvious to one of ordinary skill in the art to modify the system of Edgar with the teaching of Rogers to perform a de-identification operation on at least a portion of the received set of provider data, perform a matching operation on the at least a portion of the received set of provider data and process the matched de-identified data to extract at least one set of coded information according to a predetermined data format of the set of provider data, with the motivation of improving the quality and security of data provided, and to manage medical information in a manner that is beneficial, reliable, portable, flexible, and efficiently usable to those in the medical field, including patients [Col. 2 lines 1-7]
Claim 32. Edgar teaches The method of Claim 31, further comprising: associating one or more categorized matched de-identified data with the plurality of healthcare providers, wherein the one or more categorized matched de-identified data relate to the vitality composite score for the plurality of healthcare providers or payers. (Certain aspects interrelate people, processes, and technology both at a healthcare provider and a payer to facilitate action on denials. [0084] one or more denial categories of interest 720 can be selected with a few clicks of a mouse and/or other indication 725 of category information 720 (e.g., denied dollars, denied claim count, etc.) [0098])
Claim 33 Edgar teaches The method of Claim 31, further comprising: selectively transmitting information relating to normalized provider data for the selected healthcare provider and the comparison data to a user device, the user device being communicatively coupled to the network. (include communication interfaces to exchange information with server 330 and data store 340 via the cloud 320. [0070] observations as a fraction of a population, aggregate statistics such as a sum of metrics (e.g., cost, benefit, etc.), [0130])
Claim 34 Edgar teaches he method of Claim 33, further comprising: visually displaying the information relating to the normalized provider data for the selected healthcare provider and the comparison data on a display unit of the user device. (The display can be in the form of a network interface or graphic user interface (GUI) to exchange data, instructions, or illustrations on a computing device via communication inter face [0045] Metrics 520 can be measured by one or more criteria Such as denial count, opportunity cost, percentage of denied charges, rework cost, etc. [0094] an example interface 700 provides overview one or more denial categories of interest 720 can be selected with a few clicks of a mouse and/or other pointing/cursor control device selecting and/or hovering over a point on a graph and/or other indication 725 of category information 720 (e.g., denied dollars, denied claim count, etc.). [0098])
Claim 35 Edgar teaches the method of Claim 33, wherein the user device is configured to provide a user with access to information relating to the normalized provider data for the selected healthcare provider and the comparison data via a secure, encrypted, website URL (SHTTP), as made available by the server via the network. (Patient/provider association information may include a provider identifier, a patient identifier, an encrypted key, and one or more override security categories. Memory 140 can be structured according to provider, patient, patient/provider association, and document. [0049]);
Claim 36 Edgar teaches the method of Claim 33, further comprising: assigning each user of the user device a user type, the user type being associated with the user's level of access to data stored on the server. (Certain examples provide one or more dashboards for specific sets of patients or sets of operational data. Dashboard(s) can be based on condition, role, and/or other criteria to indicate variation(s) from a desired practice, [0039])
Claim 37 Edgar teaches the method of Claim 31, wherein each set of provider data includes 837 claim files or 835 remittance files. (par. 0079-reating an ANSI X12N claim transaction that includes all information in correct format; and submitting a claim transaction to a correct payer and within timely filing limits from the patient accounting accounts receivable system for each invoice and related services. Remittance data is received from the payer that includes payment and adjustment or denial amounts. The remittance data is posted to the correct invoice in accounts receivable. Denials for services not paid are handled, which includes understanding denial reasons, potential cause, etc.; par. 0085-Electronic data interchange (EDI) provides claim and remittance processing between a provider and a payer. A defect can be introduced at a variety of points in the process between provider and payer; [0118]- meaningful data includes healthcare EDI payment transactions (e.g., X12 documents, ANSI 837 claims, ANSI 835 remits, ANSI 277CA rejections, etc.), server logfiles, equipment fault data, machine alarm data, machine to machine status data, etc)
Claim 38. Edgar teaches the method of Claim 31, wherein the velocity index comprises a measurement of how quickly the healthcare provider is expected to collect reimbursement for performance of medical services, the value index comprises a measurement of a financial value of reimbursement to the healthcare provider, the variety index comprises a measurement of a diversification of cashflow from a plurality of payers, and the volatility index comprises a measurement risk associated with denials flowing to the healthcare provider. . (Value index; [0086]- An opportunity benchmark measures an amount of value to an enterprise if a problem can be addressed. An opportunity benchmark equals an opportunity cost…For a denial, an opportunity benchmark equals a denied cost plus a cost of labor to fix; [0101]: Included with the example view 1300 of FIG. 13 is a visualization of an “opportunity benchmark” represented by both an estimated cost of rework and an impact to working capital to an associated organization; data can include Healthcare EDI payment transactions…machine to machine status data with variables (e.g., variables that in Healthcare EDI payment transactions include denial reason codes, denial group codes, denial remark codes [0131] Metrics 520 can be scored by total amount (e.g., sum), average percent, unexpectedness, etc. [0094]));
Claim 39 Edgar teaches the method of Claim 31, wherein the encounter data includes claims data, encounter status data, remit data, remit service fine data, and/or remit adjustment data. (EDI services facilitate data exchange and processing to map patient services with claims, payer information, denials, and associated causes and recommendation [0089];)
Conclusion
The prior art made of record and not relied upon is considered pertinent to applicant's disclosure:
Delaney et al (US 20160092641 A1)-discloses a system including an improvement evaluation component 202 which can determine or infer what services are being o