Claim adjustment quality review

• US 20070067191A1
• Filed: 09/22/2005
• Published: 03/22/2007
• Est. Priority Date: 09/22/2005
• Status: Abandoned Application

• Current Assignee: Xactware Solutions, Inc. (Verisk Analytics Incorporated)
• Original Assignee: Xactware Solutions, Inc. (Verisk Analytics Incorporated)
• Inventors: Loveland, James
• Application Number:
  US11/232,695
• Publication Number:
  US 20070067191A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

The present invention relates to a financial reinspection system that allows for efficient identification of financial issues regarding claim disbursements. One embodiment of the present invention is a database system in which all claims are tracked. Each tracked claim includes a plurality of characteristics or data items such as the identity of the claim adjuster, the identity of an assigned contractor, the location of the claim, the total claim amount, etc. The claims can be searched and sorted according to any one of the data items such that patterns or potential problems can easily be identified in an efficient manner. In addition, the system includes the ability to set rules which can be used to perform particular searches automatically in real time. The results generated from the rules can then be used to further identify financial problems. The specific process utilized by the system embodiment includes analyzing data items, formulating and processing rules in real time, and implementing reinspections based on the results generated by the rules. The analysis of data items includes identifying particular data items or combinations of data items which may be more likely to be associated with financial claim problems. The formulation and processing of rules in real time includes any type of real time search with one or more of the data items of the claims. And likewise, the implementation of reinspections includes any type of actions taken as a result of the information learned from the rule results.

Claims

1. A system for quality review analysis of claims, comprising:

a claim which includes an associated data item;

a real time rule which identifies the claim according to a particular criteria based on a data item of the claim; and

a claim review performed on the claim.

2. The system of claim 1, wherein the data item consists of:

the identity of contractor, experience of contractor, location of claim, type of claim, amount of the claim, event which caused claim, financial institution, identity of claim adjuster, experience of claim adjuster, identity of claimant, and credit rating of claimant.

3. The system of claim 1 further comprising a display of claims and associated data items.

4. The system of claim 1, wherein the plurality of claims can be organized and displayed according to any one or more of the associated data items.

5. The system of claim 1, wherein the real time rule is performed automatically at a particular interval and the identified claim is displayed.

6. The system of claim 1 further including a rule generation module which allows users to generate additional real time rules in response to particular circumstances.

7. The system of claim 1, wherein the claim review includes sending a financial reinspector out to the claim site to perform a financial audit.

8. A system for quality review analysis of claims, comprising:

a plurality of claims, wherein each claim includes at least one associated data item;

at least one real time rule which identifies at least one of the plurality of claims according to a particular criteria based on the associated at least one data items of each claim;

at least one display of the identified at least one claims;

a rule making module configured to allow a user to generate additional real time rules; and

a claim review performed on any one of the identified at least one claims.

9. A method of reviewing claims, comprising the acts of:

providing a plurality of claims, wherein each claim includes at least one associated data item;

identifying at least one claim of the plurality of claims in real time according to a particular criteria based on the associated at least one data items of each claim; and

executing a claim review on the identified at least one claim.

10. The method of claim 9, wherein the at least one associated data items include at least one of the identity of contractor, experience of contractor, location of claim, type of claim, event which caused claim, financial institution, identity of claim adjuster, experience of claim adjuster, identity of claimant, and credit rating of claimant.

11. The method of claim 9 further including displaying of each of the plurality of claims and the associated at least one data items.

12. The method of claim 9, wherein the plurality of claims can be organized and displayed according to any one or more of the associated data items.

13. The method of claim 9, wherein the at least one real time rule is performed automatically at a particular interval and the identified claims are displayed.

14. The method of claim 9 further including receiving at least one customized rule from a user that specifies alternative criteria for identifying at least one of the plurality of claims using the associated at least one data items.

15. The method of claim 9, wherein the claim review includes sending a financial reinspector out to the claim site to perform a financial audit.