Secure communications

• US 10,372,878 B2
• Filed: 08/27/2015
• Issued: 08/06/2019
• Est. Priority Date: 06/30/2011
• Status: Active Grant

• Current Assignee: Verizon Patent and Licensing Incorporated (Verizon Communications Inc.)
• Original Assignee: Verizon Patent and Licensing Incorporated (Verizon Communications Inc.)
• Inventors: Van Arkel, John H., Wagner, James J., Schweyen, Corrine L., Mahone, Saralyn M., Tada, David D., Curtis, Terrill J., Hagins, Scott
• Primary Examiner(s): Pauls, John A
• Application Number:
  US14/837,950
• Publication Number:
  US 20150363557A1
• Time in Patent Office: 1,440 Days
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A system for providing secure communications may include a management system to receive first information, the first information being received via a first secure connection, analyze the received information to form analyzed information, and provide the analyzed information, a processor device to receive the analyzed information, the analyzed information being received via a second secure connection between the processor device and the management system, and perform an action based on the analyzed information, and a clearinghouse device to receive second information, the second information being received via a third secure connection between the clearinghouse device and each provider device of a plurality of provider devices, process the second information to form the first information, and provide the first information to the management system via the first secure connection.

Claims

1. A method, comprising:

receiving, by one or more computer devices of a healthcare fraud management system, a first plurality of healthcare claims;

applying, by the one or more computer devices and in real time or near real time, a plurality of rules to the first plurality of healthcare claims;

generating, by the one or more computer devices and in real time or near real time, a plurality of alarms based on applying the plurality of rules to the first plurality of healthcare claims,

a first alarm, of the plurality of alarms, being generated based on a first healthcare claim, of the first plurality of healthcare claims, and a second healthcare claim, of the first plurality of healthcare claims, that satisfy at least one rule of the plurality of rules,

the second healthcare claim being different from the first healthcare claim,

a second alarm, of the plurality of alarms, being generated based on a third healthcare claim, of the first plurality of healthcare claims, that satisfies at least one other rule of the plurality of rules,

the second alarm being different from the first alarm,

the third healthcare claim being different from the first healthcare claim and the second healthcare claim,

a third alarm, of the plurality of alarms, being generated based on at least one of the first healthcare claim, the second healthcare claim, or the third healthcare claim,

the third alarm being different from the first alarm and the second alarm;

forming, by the one or more computer devices, a first case, associated with the first healthcare claim, by combining the first alarm and the second alarm based on an attribute of two or more of the first healthcare claim, the second healthcare claim, or the third healthcare claim;

determining, by the one or more computer devices and in real time or near real time, a first case score associated with the first case;

forming, by the one or more computer devices and in real time or near real time, a second case, associated with the first healthcare claim, based on the third alarm;

determining, by the one or more computer devices and in real time or near real time, a second case score associated with the second case;

determining, by the one or more computer devices and in real time or near real time, a fraud score, associated with the first healthcare claim, based on the first case score and the second case score;

selectively applying, by the one or more computer devices and in real time or near real time, predictive modeling to information associated with the first healthcare claim to determine whether the first healthcare claim is fraudulent,

the predictive modeling being selectively applied based on whether the fraud score satisfies a threshold score, and

when the predictive modeling is applied, applying the predictive modeling including using a streaming data reduction platform to normalize and filter the information associated with the first healthcare claim to reduce the information associated with the first healthcare claim to a size that may be processed in real time or near real time;

providing, by the one or more computer devices and based on selectively applying the predictive modeling, an indication associated with the first healthcare claim,

the indication associated with the first healthcare claim being provided in real time or near real time to a claims processor device, and causing at least one of;

acceptance of the first healthcare claim prior to payment of the first healthcare claim by the claims processor device, or

denial of the first healthcare claim prior to payment of the first healthcare claim by the claims processor device;

receiving, by the one or more computer devices and in real time or near real time, a second set of one or more healthcare claims;

selectively applying, by the one or more computer devices and in real time or near real time, the predictive modeling to information associated with the second set of one or more healthcare claims to determine whether the first healthcare claim is fraudulent; and

updating, by the one or more computer devices, based on selectively applying the predictive modeling to the information associated with the second set of one or more healthcare claims, and in real time or near real time, the indication associated with the first healthcare claim.

2. The method of claim 1, where the information associated with the first healthcare claim includes one or more of:

a name associated with the first healthcare claim,

a case identification associated with the first healthcare claim,

a specialty associated with the first healthcare claim,

a cost associated with the first healthcare claim, or

a procedure associated with the first healthcare claim.

3. The method of claim 1, where the information associated with the first healthcare claim includes:

information that identifies a geographical map, and

an indication of a location of an alarm associated with the first healthcare claim,

the indication of the location being provided for display on the geographical map.

4. The method of claim 1, where the plurality of rules includes at least one of:

provider-specific rules;

provider type-specific rules;

beneficiary-specific rules;

procedure frequency-specific rules;

geographical dispersion of services-specific rules;

single claim analysis-related rules;

auto summation of provider procedure time-specific rules;

suspect beneficiary ID theft-specific rules;

alert on suspect address-specific rules;

inconsistent relationship-specific rules;

excessive cost-specific rules;

rules that identify fraudulent therapies;

or

rules that identify a gang visit fraud scheme where a provider bills as if services have been provided to all beneficiaries in a facility.

5. The method of claim 1, where providing the indication associated with the first healthcare claim comprises:

providing the indication associated with the first healthcare claim to the claims processor device in real-time or near real-time.

6. The method of claim 1, further comprising:

generating a plurality of fraud scores corresponding to the first plurality of healthcare claims,

the plurality of fraud scores including the fraud score;

generating a prioritized list of the first plurality of healthcare claims based on the plurality of fraud scores; and

providing the prioritized list of the first plurality of healthcare claims.

7. The method of claim 1, where forming the second case comprises:

forming the second case based on the first alarm or the second alarm.

8. A system, comprising:

one or more memory devices to store a plurality of rules for detecting fraud; and

one or more processors to;

receive a first plurality of claims;

apply, in real time or near real time, the plurality of rules to the first plurality of claims based on receiving the first plurality of claims;

generate, in real time or near real time, a plurality of alarms based on applying the plurality of rules to the first plurality of claims,

the plurality of alarms being generated based on a fraud detector unit transmitting the first plurality of claims to a rules engine, the rules engine applying the plurality of rules to the first plurality of claims, and the rules engine generating, based on applying the plurality of rules, the plurality of alarms,

a first alarm, of the plurality of alarms, being generated based on a first claim, of the first plurality of claims, and a second claim, of the first plurality of claims, that satisfy at least one rule of the plurality of rules,

the second claim being different from the first claim,

a second alarm, of the plurality of alarms, being generated based on a third claim, of the first plurality of claims, that satisfies at least one other rule of the plurality of rules,

the second alarm being different from the first alarm,

the third claim being different from the first claim and the second claim,

a third alarm, of the plurality of alarms, being generated based on at least one of the first claim, the second claim, or the third claim,

the third alarm being different from the first alarm and the second alarm;

form, in real time or near real time, a first case, associated with the first claim, by combining the first alarm and the second alarm based on an attribute of two or more of the first claim, the second claim, or the third claim,

the first case being formed by an alarm combiner and analyzer unit receiving the first alarm and the second alarm, analyzing the attribute, and forming the first case based on the analyzed attribute;

determine, in real time or near real time, a first case score associated with the first case,

the first case score being determined based on a fraud score generator unit receiving, from the alarm combiner and analyzer unit, information associated with the first case, analyzing the information associated with the first case, and determining the first case score based on analyzing the information associated with the first case;

form, in real time or near real time, a second case, associated with the first claim, based on the third alarm,

the second case being formed by the alarm combiner and analyzer unit receiving the third alarm, analyzing an attribute associated with the third alarm, and forming the second case based on the analyzed attribute associated with the third alarm;

determine, in real time or near real time, a second case score associated with the second case,

the second case score being determined based on the fraud score generator unit receiving, from the alarm combiner and analyzer unit, information associated with the second case, analyzing the information associated with the second case, and determining the second case score based on analyzing the information associated with the second case;

determine, in real time or near real time, a fraud score, for the first claim, based on the first case score and the second case score;

selectively apply, in real time or near real time, predictive modeling to information associated with the first claim to determine whether the first claim is fraudulent,

the predictive modeling being selectively applied based on whether the fraud score satisfies a threshold score, and

when the predictive modeling is applied, applying the predictive modeling including using a streaming data reduction platform to normalize and filter the information associated with the first claim to reduce the information associated with the first claim to a size that may be processed in real time or near real time;

provide, based on selectively applying the predictive modeling, an indication associated with the first claim,

the indication associated with the first claim being provided in real time or near real time to a claims processor device, and causing at least one of;

acceptance of the first claim prior to payment of the first claim by the claims processor device, or

denial of the first claim prior to payment of the first claim by the claims processor device;

receive, in real time or near real time, a second set of one or more claims;

selectively apply, in real time or near real time, the predictive modeling to information associated with the second set of one or more claims to determine whether the first claim is fraudulent; and

update, based on selectively applying the predictive modeling to the information associated with the second set of one or more claims and in real time or near real time, the indication associated with the first claim.

9. The system of claim 8, where the information associated with the first claim includes a list of alarms associated with the first claim.

10. The system of claim 8, where the information associated with the first claim includes:

information that identifies a geographical map associated with the first claim; and

an indication, provided in association with the geographical map, of a location associated with at least one of;

the first alarm,

the second alarm, or

the third alarm.

11. The system of claim 8, where the plurality of rules includes at least one of:

provider-specific rules;

provider type-specific rules;

beneficiary-specific rules;

procedure frequency-specific rules;

geographical dispersion of services-specific rules;

single claim analysis-related rules;

auto summation of provider procedure time-specific rules;

suspect beneficiary ID theft-specific rules;

alert on suspect address-specific rules;

inconsistent relationship-specific rules;

excessive cost-specific rules;

rules that identify fraudulent therapies;

or

rules that identify a gang visit fraud scheme where a provider bills as if services have been provided to all beneficiaries in a facility.

12. The system of claim 8, where the indication associated with the first claim is provided to the claims processor device to accept or deny the first claim.

13. The system of claim 8, where the one or more processors are further to:

generate a plurality of fraud scores corresponding to the plurality of claims,

the plurality of fraud scores including the fraud score;

generate a prioritized list of the plurality of claims based on the plurality of fraud scores; and

provide the prioritized list.

14. The system of claim 8, where the one or more processors, when forming the second case, are to:

form the second case based on the first alarm.

15. A non-transitory computer-readable medium storing instructions, the instructions comprising:

one or more instructions that, when executed by one or more processors, cause the one or more processors to;

receive a first plurality of claims;

apply, in real time or near real time, a plurality of rules to the first plurality of claims based on receiving the first plurality of claims;

generate, in real time or near real time, a plurality of alarms based on applying the plurality of rules to the first plurality of claims,

the plurality of alarms being generated based on a fraud detector unit transmitting the first plurality of claims to a rules engine, the rules engine applying the plurality of rules to the first plurality of claims, and the rules engine generating, based on applying the plurality of rules, the plurality of alarms,

a first alarm, of the plurality of alarms, being generated based on a first claim, of the first plurality of claims, and a second claim, of the first plurality of claims, that satisfy at least one rule of the plurality of rules,

the second claim being different from the first claim,

a second alarm, of the plurality of alarms, being generated based on a third claim, of the first plurality of claims, that satisfies at least one other rule of the plurality of rules,

the second alarm being different from the first alarm,

the third claim being different from the first claim and the second claim,

a third alarm, of the plurality of alarms, being generated based on at least one of the first claim, the second claim, or the third claim,

the third alarm being different from the first alarm and the second alarm;

form, in real time or near real time, a first case, associated with the first claim, by combining the first alarm and the second alarm based on an attribute of two or more of the first claim, the second claim, or the third claim,

the first case being formed by an alarm combiner and analyzer unit receiving the first alarm and the second alarm, analyzing the attribute, and forming the first case based on the analyzed attribute;

determine, in real time or near real time, a first case score associated with the first case,

the first case score being determined based on a fraud score generator unit receiving, from the alarm combiner and analyzer unit, information associated with the first case, analyzing the information associated with the first case, and determining the first case score based on analyzing the information associated with the first case;

form, in real time or near real time, a second case, associated with the first claim, based on the third alarm,

the second case being formed by the alarm combiner and analyzer unit receiving the third alarm, analyzing an attribute associated with the third alarm, and forming the second case based on the analyzed attribute associated with the third alarm;

determine, in real time or near real time, a second case score associated with the second case,

the second case score being determined based on the fraud score generator unit receiving, from the alarm combiner and analyzer unit, information associated with the second case, analyzing the information associated with the second case, and determining the second case score based on analyzing the information associated with the second case;

determine, in real time or near real time, a fraud score, for the first claim, based on the first case score and the second case score;

selectively apply, in real time or near real time, predictive modeling to information associated with the first claim to determine whether the first claim is fraudulent,

the predictive modeling being selectively applied based on whether the fraud score satisfies a threshold score, and

when the predictive modeling is applied, applying the predictive modeling including using a streaming data reduction platform to normalize and filter the information associated with the first claim to reduce the information associated with the first claim to a size that may be processed in real time or near real time; and

provide, based on selectively applying the predictive modeling, an indication associated with the first claim,

the indication associated with the first claim being provided in real time or near real time to a claims processor device, and causing at least one of;

acceptance of the first claim prior to payment of the first claim by the claims processor device, or

denial of the first claim prior to payment of the first claim by the claims processor device;

receive, in real time or near real time, a second set of one or more claims;

selectively apply, in real time or near real time, the predictive modeling to information associated with the second set of one or more claims to determine whether the first claim is fraudulent; and

update, based on selectively applying the predictive modeling to the information associated with the second set of one or more claims, and in real time or near real time, the indication associated with the first claim.

16. The non-transitory computer-readable medium of claim 15, where the information associated with the first claim includes:

information that identifies the first alarm, the second alarm, or the third alarm.

17. The non-transitory computer-readable medium of claim 15, where the information associated with the first claim includes:

information that identifies a geographical map associated with the first claim, and

an indication of a location, represented on the geographical map, of an alarm associated with the first claim.

18. The non-transitory computer readable medium of claim 15, where the one or more instructions, when executed by the one or more processors, further cause the one or more processors to:

generate a plurality of fraud scores corresponding to the plurality of claims,

the plurality of fraud scores including the fraud score;

generate a prioritized list of the plurality of claims based on the plurality of fraud scores; and

provide the prioritized list for display.

19. The non-transitory computer readable medium of claim 15, where the one or more instructions, that cause the one or more processors to form the second case, cause the one or more processors to:

form the second case based on the second alarm.

20. The non-transitory computer readable medium of claim 15, where the plurality of rules includes at least one of:

provider-specific rules;

provider type-specific rules;

beneficiary-specific rules;

procedure frequency-specific rules;

geographical dispersion of services-specific rules;

single claim analysis-related rules;

auto summation of provider procedure time-specific rules;

suspect beneficiary ID theft-specific rules;

alert on suspect address-specific rules;

inconsistent relationship-specific rules;

excessive cost-specific rules;

rules that identify fraudulent therapies;

or

rules that identify a gang visit fraud scheme where a provider bills as if services have been provided to all beneficiaries in a facility.