COMPUTER SYSTEM FOR ANALYZING CLAIMS FILES TO IDENTIFY PREMIUM FRAUD
First Claim
1. A computer system comprising:
- a data storage module for receiving, storing, and providing access to aggregate claims file data, said aggregate claims file data representing claims for workers compensation benefits under a plurality of workers compensation insurance policies, said aggregate claims file data including unstructured text fields that contain unstructured text information, said data storage module also receiving, storing and providing access to policy data that relates to said plurality of workers compensation insurance policies;
a text mining component, coupled to the data storage module, for determining whether to identify a one of said workers compensation insurance policies for referral to an investigation unit, wherein said determining includes analyzing unstructured text information contained in aggregate claims file data for said one of said workers compensation insurance policies, said analyzing for detecting at least one indicator of premium fraud in said unstructured text information;
a computer processor, coupled to the data storage module, for executing programmed instructions and for storing and retrieving said aggregate claims file data and said policy data;
program memory, coupled to the computer processor, for storing program instruction steps for execution by the computer processor;
an output device, coupled to the computer processor, for outputting an output indicative of whether said one of said workers compensation insurance policies should be referred to the investigation unit, wherein the computer processor generates the output in accordance with program instructions in the program memory and executed by the computer processor, said output generated in response to analyzing the unstructured text information contained in the aggregate claims file data for said one of said workers compensation insurance policies; and
a routing module for directing workflow based on the output from the output device.
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Accused Products
Abstract
A computer system includes a data storage module. The data storage module receives, stores, and provides access to both aggregate claims file data and insurance policy data. The computer system also includes a computer processor and a program memory. The computer processor executes programmed instructions and stores and retrieves the data stored in the data storage module. A text mining component is coupled to the data storage module, and analyzes unstructured text in the aggregate claims file data to detect indicators of possible premium fraud. A routing module in the computer system routes for investigation insurance policies that correspond to the claim files in which indicators of possible premium fraud were detected.
27 Citations
29 Claims
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1. A computer system comprising:
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a data storage module for receiving, storing, and providing access to aggregate claims file data, said aggregate claims file data representing claims for workers compensation benefits under a plurality of workers compensation insurance policies, said aggregate claims file data including unstructured text fields that contain unstructured text information, said data storage module also receiving, storing and providing access to policy data that relates to said plurality of workers compensation insurance policies; a text mining component, coupled to the data storage module, for determining whether to identify a one of said workers compensation insurance policies for referral to an investigation unit, wherein said determining includes analyzing unstructured text information contained in aggregate claims file data for said one of said workers compensation insurance policies, said analyzing for detecting at least one indicator of premium fraud in said unstructured text information; a computer processor, coupled to the data storage module, for executing programmed instructions and for storing and retrieving said aggregate claims file data and said policy data; program memory, coupled to the computer processor, for storing program instruction steps for execution by the computer processor; an output device, coupled to the computer processor, for outputting an output indicative of whether said one of said workers compensation insurance policies should be referred to the investigation unit, wherein the computer processor generates the output in accordance with program instructions in the program memory and executed by the computer processor, said output generated in response to analyzing the unstructured text information contained in the aggregate claims file data for said one of said workers compensation insurance policies; and a routing module for directing workflow based on the output from the output device. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14)
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15. A computer system comprising:
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a data storage module for receiving, storing, and providing access to aggregate claims file data, said aggregate claims file data representing claims made under a plurality of insurance policies, said aggregate claims file data including unstructured text fields that contain unstructured text information, said data storage module also receiving, storing and providing access to policy data that relates to said plurality of insurance policies; a text mining component, coupled to the data storage module, for determining whether to identify a one of said insurance policies for referral to an investigation unit, wherein said determining includes analyzing unstructured text information contained in aggregate claims file data for said one of said insurance policies, said analyzing for detecting at least one indicator of premium fraud in said unstructured text information; a computer processor, coupled to the data storage module, for executing programmed instructions and for storing and retrieving said aggregate claims file data and said policy data; program memory, coupled to the computer processor, for storing program instruction steps for execution by the computer processor; an output device, coupled to the computer processor, for outputting an output indicative of whether said one of said insurance policies should be referred to the investigation unit, wherein the computer processor generates the output in accordance with program instructions in the program memory and executed by the computer processor, said output generated in response to analyzing the unstructured text information contained in the aggregate claims file data for said one of said insurance policies; and a routing module for directing workflow based on the output from the output device. - View Dependent Claims (16, 17, 18, 19, 20, 21, 22, 23)
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24. A method of operating a computer system to identify premium fraud in workers compensation insurance policies, the method comprising:
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storing aggregate claims file data in the computer system, said aggregate claims file data representing claims for workers compensation benefits under a plurality of workers compensation insurance policies, said aggregate claims file data including unstructured text fields that contain unstructured text information; storing policy data in the computer system, said policy data relating to said plurality of workers compensation insurance policies; using in said computer system a text mining tool to define at least one rule for identifying at least one indicator of premium fraud in said unstructured text information; automatically analyzing said unstructured text information in said stored aggregate claims file data by using said at least one rule and said text mining tool to select ones of said workers compensation insurance policies, said selected ones of said workers compensation insurance policies corresponding to ones of said claims for which said analyzing identified said at least one indicator of premium fraud; generating output signals in the computer system, said output signals including portions of said policy data, said portions of said policy data corresponding to said selected ones of said workers compensation insurance policies, said output signals also including data that represents said at least one indicator of premium fraud identified by said analyzing; and outputting said output signals from said computer system. - View Dependent Claims (25, 26, 27, 28, 29)
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Specification