SYSTEM AND METHOD FOR KNOWLEDGE-DRIVEN PRESENTATION OF MEDICAL CLAIM INFORMATION

• US 20110040580A1
• Filed: 08/11/2009
• Published: 02/17/2011
• Est. Priority Date: 08/11/2009
• Status: Abandoned Application

• Current Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Original Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Inventors: Maurer, Kathleen F., McLaughlin, Kelly J.
• Application Number:
  US12/539,015
• Publication Number:
  US 20110040580A1
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/08 Logistics, e.g. warehousing, loading or distribution; Inventory or stock management
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems

Abstract

A computerized system includes acquisition of cost data associated with a workers'"'"' compensation claim from a data storage device, reception of a request to display the cost data associated with the workers'"'"' compensation claim from a remote terminal, application of knowledge-based graphing rules to the cost data to identify a medically-relevant characteristic of the cost data, and output, to a client device, of a graphical representation of the requested cost data including a graphical indication of the identified medically-relevant characteristic.

Claims

1. A computer system comprising:

a data storage device for receiving, storing, and providing access to claim cost data associated with a workers'"'"' compensation claim of a single claimant;

a computer processor for executing program instructions and for retrieving the claim cost data from the data storage device;

a memory, coupled to the computer processor, for storing program instructions for execution by the computer processor;

a grouping engine comprising program instructions stored in the memory for grouping the claim cost data into medical categories based on knowledge-based grouping rules when executed by the computer processor;

a rules engine comprising program instructions stored in the memory for applying knowledge-based graphing rules to the grouped claim cost data to identify a medically-relevant characteristic of the grouped claim cost data when executed by the computer processor; and

a communication device, coupled to the computer processor, to output a graphical representation of the grouped claim cost data including a graphical indication of the medically-relevant characteristic.

2. A computer system according to claim 1, wherein at least one of the knowledge-based grouping rules and the knowledge-based graphing rules may be changed dynamically.

3. A system according to claim 1, wherein the claim cost data comprises payment data, medical bill data, procedure codes and diagnostic codes.

4. A system according to claim 1, the program instructions stored in the memory for receiving a request to display cost data associated with the workers'"'"' compensation claim and with one set of a plurality of sets of medical categories determined based on the knowledge-based grouping rules.

5. A system according to claim 4, wherein the knowledge-based graphing rules are applied to the cost data associated with the workers'"'"' compensation claim and the specified medical categories.

6. A system according to claim 1, wherein the medical categories comprise narcotics-immediate release, narcotics-short acting, and narcotics-long acting.

7. A system according to claim 1, wherein the knowledge-based graphing rules comprise:

a rule to identify an increase of a medical cost associated with a medical category that is greater than a specified amount over a specified period.

8. A system according to claim 1, wherein the knowledge-based graphing rules comprise:

a rule to identify an increase of a medical cost associated with a medical category over a specified period.

9. A system according to claim 1, wherein the knowledge-based graphing rules comprise:

a rule to identify a sustained medical cost amount associated with a medical category that is greater than a specified amount over a specified period.

10. A system according to claim 1, wherein the knowledge-based graphing rules comprise:

a rule to identify a medical cost amount associated with a medical category that is greater than a specified amount.

11. A system according to claim 1, further comprising:

a remote terminal to receive and to display the graphical representation to an adjuster and to receive an instruction from the adjuster to perform an insurance-based action associated with the workers'"'"' compensation claim; and

an insurance-related database to perform the insurance-based action based on the instruction.

12. A system according to claim 1, further comprising:

a remote terminal to receive and to display the graphical representation to medical personnel to receive an instruction from the medical personnel to provide information to a medical application server associated with the medical claim; and

a medical application server to initiate the medical service based on the instruction.

13. A computerized method comprising:

acquiring cost data associated with a workers'"'"' compensation claim from a data storage device;

receiving a request to display the cost data associated with the worker'"'"' compensation claim from a remote terminal;

applying knowledge-based graphing rules to the cost data to identify a medically-relevant characteristic of the cost data; and

outputting, to a client device, a graphical representation of the requested cost data including a graphical indication of the identified medically-relevant characteristic.

14. A method according to claim 13, wherein the claim cost data comprises payment data, medical bill data, procedure codes and diagnostic codes.

15. A method according to claim 13, further comprising:

receiving an instruction from a second remote terminal to dynamically change the knowledge-based graphing rules.

16. A method according to claim 13, further comprising:

grouping the claim cost data into medical categories based on knowledge-based grouping rules,

wherein the knowledge-based graphing rules are applied to the cost data to identify the medically-relevant characteristic of the cost data.

17. A method according to claim 16, further comprising:

receiving an instruction from a second remote terminal to dynamically change the knowledge-based grouping rules.

18. A method according to claim 13, wherein the request comprises a request to display the cost data associated with the workers'"'"' compensation claim and with one set of a plurality of sets of medical categories, and

wherein each of the plurality of sets of medical categories comprises a group of medical categories grouped based on knowledge-based grouping rules.

19. A method according to claim 18, wherein the knowledge-based graphing rules are applied to the cost data associated with the workers'"'"' compensation claim and the specified medical categories.

20. A method according to claim 13, wherein the medical categories comprise narcotics-immediate release, narcotics-short acting, and narcotics-long acting.

21. A method according to claim 13, wherein the knowledge-based rules comprise:

a rule to identify an increase of a medical cost associated with a medical category that is greater than a specified amount over a specified period.

22. A method according to claim 13, wherein the knowledge-based rules comprise:

a rule to identify an increase of a medical cost associated with a medical category over a specified period.

23. A method according to claim 13, wherein the knowledge-based rules comprise:

a rule to identify a sustained medical cost amount associated with a medical category that is greater than a specified amount over a specified period.

24. A method according to claim 13, wherein the knowledge-based rules comprise:

a rule to identify a medical cost amount associated with a medical category that is greater than a specified amount.

25. A method according to claim 13, further comprising:

presenting, on a remote terminal, the graphical representation to medical personnel;

receiving, at the remote terminal, an instruction from the medical personnel to perform a medical service associated with the medical claim; and

initiating, at a medical application server, the medical service based on the instruction.

26. A method according to claim 13, further comprising:

presenting, on a remote terminal, the graphical representation to an adjuster;

receiving, at the remote terminal, an instruction from an adjuster to perform an insurance-based action associated with the workers'"'"' compensation claim based on the graphical representation; and

performing the insurance-based action in an insurance database based on the instruction.

27. A computer system comprising:

a data storage device for receiving, storing, and providing access to claim cost data associated with an insurance claim of a single claimant and grouped into medical categories;

a computer processor for executing program instructions and for retrieving the claim cost data from the data storage device;

a memory, coupled to the computer processor, for storing program instructions for execution by the computer processor;

a rules engine comprising program instructions stored in the memory for applying knowledge-based graphing rules to grouped claim cost data to identify a medically-relevant characteristic of the grouped claim cost data when executed by the computer processor; and

a communication device, coupled to the computer processor, to output a graphical representation of the grouped claim cost data including a graphical indication of the medically-relevant characteristic.

28. A computer system according to claim 27, wherein the knowledge-based graphing rules may be changed dynamically.

29. A system according to claim 27, wherein the knowledge-based graphing rules comprise:

a rule to identify an increase of a medical cost associated with a medical category that is greater than a specified amount over a specified period.

30. A system according to claim 27, wherein the knowledge-based graphing rules comprise:

a rule to identify an increase of a medical cost associated with a medical category over a specified period.

31. A system according to claim 27, wherein the knowledge-based graphing rules comprise:

a rule to identify a sustained medical cost amount associated with a medical category that is greater than a specified amount over a specified period.

32. A system according to claim 27, wherein the knowledge-based graphing rules comprise:

a rule to identify a medical cost amount associated with a medical category that is greater than a specified amount.