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Predictive model-based discriminator

  • US 10,176,528 B2
  • Filed: 06/24/2016
  • Issued: 01/08/2019
  • Est. Priority Date: 04/08/2008
  • Status: Active Grant
First Claim
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1. A computer system comprising:

  • an indeterminate data capture component, including a natural language processing application, configured to;

    receive raw indeterminate data corresponding to historical claim transactions and current claim transactions; and

    extract indeterminate data from the raw indeterminate data, comprising text data, indicative of the historical claim transactions and the current claim transactions, and to mine opinion data from the text data;

    a predictive model component, configured to;

    train the predictive model component, based on determinate data and the extracted indeterminate data corresponding to the historical claim transactions, to generate a value indicative of whether a claim is questionable; and

    adapt the predictive model component to changing patterns of questionable claim transactions by periodically updating the predictive model component based on new determinate data and new extracted indeterminate data;

    a screening module configured to compare each of the current claim transactions to the data indicative of claim categories that are highly unlikely to be questionable;

    a computer processor configured to;

    categorize, based on application of the screening module, each of said current claim transactions as one of (1) a current claim suitable for analysis by a computerized predictive model when the current claim transaction does not correspond to a plurality of claim categories that are highly unlikely to be questionable, and (2) a current claim not suitable for analysis by the computerized predictive model when the current claim transaction corresponds to at least one of the claim categories that are highly unlikely to be questionable;

    responsive to a categorization of one or more current claim transactions as not suitable for analysis by the computerized predictive model, transmit an electronic claim file to a claims processing computer; and

    responsive to a categorization of one or more current claim transactions as suitable for analysis by the computerized predictive model;

    determine, by application of the predictive model component to each of the one or more current claim transactions categorized as suitable for analysis by the computerized predictive model, a value indicative of whether the current claim transaction is questionable;

    output, by an output device coupled to the computer processor, for each of the current claim transactions categorized as suitable for analysis by the computerized predictive model, the determined value indicative of whether the current claim transaction is questionable;

    a routing module configured to;

    responsive to a determination that the outputted value exceeds a threshold value, transmit data indicative of an electronic case file for the one of the current claim transactions to an investigation unit computer; and

    responsive to a determination that the outputted value does not exceed the threshold value, transmit data indicative of an electronic case file to a claims processing computer; and

    a data storage unit configured to receive, store, and provide access to the indeterminate data and determinate data corresponding to the historical claim transactions and to the current claim transactions, and the data indicative of claim categories that are highly unlikely to be questionable.

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