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