EVALUATING EFFECTIVENESS OF CLAIMS EVALUATION, ASSESSMENT, AND SETTLEMENT PROCESSES

• US 20090187428A1
• Filed: 06/06/2008
• Published: 07/23/2009
• Est. Priority Date: 01/18/2008
• Status: Abandoned Application

• Current Assignee: Computer Sciences Corporation (DXC Technology Company)
• Original Assignee: Computer Sciences Corporation (DXC Technology Company)
• Inventors: Henry, Scott, Dulock, Scott, Scalet, Frank, Watters, Clifton
• Application Number:
  US12/134,977
• Publication Number:
  US 20090187428A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 50/188 Electronic negotiation

Abstract

Methods and systems are provided for evaluating processes for insurance claim estimation and settlement. Data may be provided for closed claims that have been previously settled using an estimation and settlement process. Each closed claim in the data is treated as a candidate claim. For each candidate closed claim, a set of closed claims similar to the candidate closed claim is identified based on characteristics of the candidate closed claim. For each set of similar claims so identified, a representative value for the set of similar claims, such as an arithmetic mean, is determined. The settlement values for the candidate closed claims are compared to the representative values for the sets of similar closed claims.

Claims

1-127. -127. (canceled)

128. A method of evaluating an insurance claim estimation and settlement process, comprising:

providing closed claim data for closed claims that have been previously settled using the estimation and settlement process;

for one or more candidate closed claims from the closed claim data;

identifying a set of one or more closed claims that are similar to the candidate closed claim based on one or more characteristics of the candidate closed claim; and

determining a representative value for the set of similar closed claims;

automatically comparing on an insurance claim processing system settlement values of one or more of the candidate closed claims to the representative values for one or more of the sets of similar closed claims; and

evaluating consistency of the claims estimation and settlement process based on at least one comparison.

129. The method of claim 128, further comprising reporting an effectiveness of the claims estimation and settlement process based on the at least one comparison.

130. The method of claim 128, further comprising recommending at least one process change or improvement based on the at least one comparison.

131. The method of claim 128, further comprising projecting an impact from implementing a change or improvement in the insurance claim estimation and settlement process based on the at least one comparison of the settlement values of the candidate claims to the settlement values to the representative values of the set of similar claims.

132. The method of claim 128, wherein at least one of the representative values is a mean of the settled values of the closed claims in the set of similar closed claims.

133. The method of claim 128, wherein at least one of the representative values is a median of the settled values of the closed claims in the set of similar closed claims.

134. The method of claim 128, wherein at least one of the representative values is a mid-zone value for the settled values of the closed claims in the set of similar closed claims.

135. The method of claim 128, wherein the evaluation of the consistency of the claims estimation and settlement process is based on a comparison of all the claims settled by an FSO using the claim estimation and settlement process.

136. The method of claim 128, wherein the evaluation of the consistency of the claims estimation and settlement process is based on a comparison of all the claims settled by an FSO having specified characteristics.

137. The method of claim 128, wherein the settlement value of the candidate closed claim is a general damages value and the representative values of the sets of similar closed claims are computed from general damages values for the similar closed claims.

138. The method of claim 128, wherein identifying the set of one or more closed claims that are similar to the candidate closed claim comprises determining whether a major injury for the open claim is predominantly a demonstrable injury or not a demonstrable injury.

139. The method of claim 128, wherein identifying the set of one or more closed claims that are similar to the candidate closed claim comprises determining a most injured body part for the open claim.

140. The method of claim 128, wherein identifying the set of one or more closed claims that are similar to the candidate closed claim comprises determining one or more medical codes for at least one injury to a claimant for the open claim.

141. The method of claim 128, wherein identifying the set of one or more closed claims that are similar to the candidate closed claim a dominant medical feature associated with at least one injury to a claimant for the open claim.

142. The method of claim 128, wherein identifying the set of one or more closed claims that are similar to the candidate closed claim comprises applying at least one filter to the set of closed claim data.

143. A system, comprising:

a processor;

a memory coupled to the processor and configured to store program instructions executable by the processor to implement;

providing closed claim data for closed claims that have been previously settled using the estimation and settlement process;

for one or more candidate closed claims from the closed claim data;

identifying a set of one or more closed claims that are similar to the candidate closed claim based on one or more characteristics of the candidate closed claim; and

determining a representative value for the set of similar closed claims;

comparing settlement values of one or more of the candidate closed claims to the representative values for one or more of the sets of similar closed claims; and

evaluating consistency of the claims estimation and settlement process based on at least one comparison of the settlement values of the candidate claims to the settlement values to the representative values of the set of similar claims.

144. A tangible, computer readable medium comprising program instructions, wherein the program instructions are computer-executable to implement:

providing closed claim data for closed claims that have been previously settled using the estimation and settlement process;

for one or more candidate closed claims from the closed claim data;

identifying a set of one or more closed claims that are similar to the candidate closed claim based on one or more characteristics of the candidate closed claim; and

determining a representative value for the set of similar closed claims;

comparing settlement values of one or more of the candidate closed claims to the representative values for one or more of the sets of similar closed claims; and

evaluating consistency of the claims estimation and settlement process based on at least one comparison of the settlement values of the candidate claims to the settlement values to the representative values of the set of similar claims.

145. A method of evaluating an insurance claim estimation and settlement process, comprising:

providing a plurality of candidate claims, the candidate claims having an associated general damages value;

for at least one of the candidate claims;

identifying a set of one or more claims that are similar to a candidate claim based on one or more characteristics of the candidate claim and the one or more similar claims; and

determining a representative general damages value for the set of similar claims;

calculating a total general damages value for two or more of the candidate claims, wherein the total general damages value is the sum of the general damages values for the two or more candidate claims;

calculating a total representative general damages value for two or more of the sets of similar claims, wherein the total general damages value is the sum of the representative general damages values determined for the sets of similar claims identified for the two or more candidate claims; and

calculating a difference between the total general damages for the candidate claims and total representative general damages for the sets of similar claims.

146. The method of claim 145, further comprising determining a potential impact of a process improvement based on the difference between the total general damages value for the candidate claims and total representative general damages value for the sets of similar claims.

148-168. -168. (canceled)