Predictive model-based discriminator
First Claim
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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Abstract
A computer system includes a data storage module which receives, stores, and provides access to determinate data, raw indeterminate data, and extracted indeterminate data captured by an indeterminate data capture module. The computer system also includes a computer processor, a model training component, and a screening module. The model training component generates the predictive model based upon historical determinate and indeterminate data, and continuously adapts the predictive model with new historical data. The screening module categorizes current claims according to whether they are suitable for predictive analysis by the predictive model. The predictive model is applied to the current claims suitable for predictive analysis to determine a value for each claim indicative of whether the current claim transaction is questionable. The system also includes an output device which outputs the determined value for each claim, and a routing modules which routes claim workflow based on the outputted values.
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Citations
12 Claims
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1. A computer system comprising:
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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. - View Dependent Claims (2, 3, 4, 5, 6)
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7. A computer-implemented method comprising:
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receiving determinate data and raw indeterminate data corresponding to historical claim transactions and current claim transactions; extracting, by one or more computer processors, from the raw indeterminate data by an indeterminate data capture module, indeterminate data comprising text data, the indeterminate data capture module including a natural language processing application to mine opinion data from the text data; storing, in a data storage device, the determinate data and the extracted indeterminate data; training, by a model training component, a predictive model component for evaluating claims for referral to an investigation unit based on the determinate data and the extracted indeterminate data related to the historical claim transactions, to generate a value indicative of whether a claim is questionable; adapting 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; comparing, by a screening module, each of the current claim transactions to the data indicative of claim categories that are highly unlikely to be questionable; categorizing, 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 the claim categories that are highly unlikely to be questionable, and (2) a current claim not suitable for analysis by a 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, transmitting an electronic claim file to a claims processing computer; responsive to a categorization of one or more current claim transactions as suitable for analysis by the computerized predictive model; determining, 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; outputting, by an output device coupled to the one or more computer processors, 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; and directing, by a routing module, workflow including; determining whether the outputted value for each of said current claim transactions categorized as suitable for predictive analysis exceeds a threshold value indicative of a claim being advisable for referral to an investigation unit computer; responsive to a determination that the outputted value exceeds the threshold value, transmitting 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, transmitting data indicative of an electronic case file to a claims processing computer. - View Dependent Claims (8, 9, 10, 11, 12)
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Specification