Enriched system for suspicious interaction record detection
First Claim
1. A method for improving efficiency for a computing device used to detect entities engaged in suspicious activity, comprising:
- collecting interaction records;
parsing the interaction records to determine a first entity, a second entity, and an interaction between the first entity and the second entity for each of the interaction records;
analyzing the parsed interaction records to produce an aggregated metric based on a statistical baseline of interactions between the first entity and the second entity;
aggregating the interaction records that include a given first entity;
generating an enriched relationship record that includes links to related entities and aggregated metrics corresponding to deviations from statistical baselines of properties of the related entities from the aggregated interaction records that include the given first entity;
auditing the enriched relationship record for the given first entity according to a set of auditing rules that incorporate a rule/threshold pair with an adjustable threshold for each property of the enriched relationship record to determine a suspicion level for the given first entity, wherein the adjustable threshold for each property of the enriched relationship record allows a specified number of suspicious activities for a given property before flagging the given first entity as suspicious and/or raising a suspicion level for the given first entity to prevent false positives absent ignoring suspicious activities;
storing the enriched relationship record in an enriched relationships database;
generating a report based on the suspicion level; and
transmitting the report to a third party.
2 Assignments
0 Petitions
Accused Products
Abstract
Systems and methods for improved detection of fraud, waste, and abuse are provided, based on the analysis of enriched relationships and aggregated metrics thereof. An enriched relationship record associates patient and provider information to provide an enhanced view of patient data, provider data, and interaction data for a given entity. Aggregated metrics provide an enhanced view of a particular entity'"'"'s activities based on the entity'"'"'s interactions with other entities and data and metadata from the related entities'"'"' enriched relationship records. The enriched relationship records and aggregated metrics may be used to audit the entity and produce a report indicative of suspicion levels for the entity engaging in fraud, waste, or abuse.
58 Citations
20 Claims
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1. A method for improving efficiency for a computing device used to detect entities engaged in suspicious activity, comprising:
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collecting interaction records; parsing the interaction records to determine a first entity, a second entity, and an interaction between the first entity and the second entity for each of the interaction records; analyzing the parsed interaction records to produce an aggregated metric based on a statistical baseline of interactions between the first entity and the second entity; aggregating the interaction records that include a given first entity; generating an enriched relationship record that includes links to related entities and aggregated metrics corresponding to deviations from statistical baselines of properties of the related entities from the aggregated interaction records that include the given first entity; auditing the enriched relationship record for the given first entity according to a set of auditing rules that incorporate a rule/threshold pair with an adjustable threshold for each property of the enriched relationship record to determine a suspicion level for the given first entity, wherein the adjustable threshold for each property of the enriched relationship record allows a specified number of suspicious activities for a given property before flagging the given first entity as suspicious and/or raising a suspicion level for the given first entity to prevent false positives absent ignoring suspicious activities; storing the enriched relationship record in an enriched relationships database; generating a report based on the suspicion level; and transmitting the report to a third party. - View Dependent Claims (2, 3, 4, 5, 6, 7)
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8. A system for improving efficiency for a computing device used to detect entities engaged in suspicious activity, comprising:
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a processor; and a memory storage device including instructions, which when executed by the processor cause the system to provide; a relationship enricher, operable to collect information related to the entities and interactions between the entities, and further operable to process the collected information to produce an enriched relationship record that includes links to related entities and aggregated metrics corresponding to deviations from statistical baselines of properties of the related entities for a given entity based on a number of aggregated interaction records; an aggregator, operable to statistically analyze a plurality of enriched relationship records to produce a statistical baseline for a property of the plurality of enriched relationship records, and further operable to produce an aggregated metric for the plurality of enriched relationship records based on the statistical baseline and a statistical rule; an enriched relationships database to store the enriched relationship records; an auditing engine, operable to audit the enriched relationship record for the given entity according to auditing rules that incorporate a rule/threshold pair with an adjustable threshold for each property of the enriched relationship record to produce a suspicion level for the given entity, wherein the adjustable threshold for each property of the enriched relationship record allows a specified number of suspicious activities for a given property before flagging the given entity as suspicious and/or raising a suspicion level for the given entity to prevent false positives for the audit absent ignoring suspicious activities; and a reporter, operable to generate a report based on the suspicion level, wherein the reporter is further operable to transmit the report to a payor. - View Dependent Claims (9, 10, 11, 12, 13, 14)
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15. A system for improving efficiency for a computing device used to detect entities engaged in suspicious activity, comprising:
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a processor that generates an enriched relationship record that includes links to related entities and aggregated metrics corresponding to deviations from statistical baselines of properties of the related entities based on aggregated interaction records for an entity according to collected information related to patients, providers, and interactions between patients and providers that include the entity; an enriched relationships database for storing the enriched relationship record; and a first rules database for storing a statistical rule; a second rules database for storing auditing rules; wherein the processor further produces a statistical baseline by statistically analyzing a plurality of enriched relationship records to produce an aggregated metric for the plurality of enriched relationship records based on the statistical rule, wherein the processor audits the enriched relationship record for the entity according to the auditing rules that incorporate a rule/threshold pair with an adjustable threshold for each property of the enriched relationship record, wherein the adjustable threshold for each property of the enriched relationship record allows a specified number of suspicious activities for a given property before flagging the entity as suspicious and/or raising a suspicion level for the entity to prevent false positives for the audit absent ignoring suspicious activities; and wherein the processor further compares each property of the enriched relationship record to a corresponding threshold to determine whether a property of the enriched relationship record is outside of the threshold, and when it is determined that the property of the enriched relationship record is outside of the corresponding threshold, generate a report indicating that the entity is suspicious, and transmit the report. - View Dependent Claims (16, 17, 18, 19, 20)
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Specification