COMPUTER SYSTEM FOR APPLYING PROACTIVE REFERRAL MODEL TO LONG TERM DISABILITY CLAIMS

• US 20110173030A1
• Filed: 03/22/2011
• Published: 07/14/2011
• Est. Priority Date: 08/22/2008
• Status: Active Grant

• Current Assignee: Timothy J. Scully
• Original Assignee: Timothy J. Scully
• Inventors: Scully, Timothy J.
• Granted Patent: US 8,359,255 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 10/1095 Meeting or appointment
• CPC Class Codes: G06Q 30/0202 Market predictions or forecasting for commercial activities
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/04 Trading; Exchange, e.g. stocks, commodities, derivatives or currency exchange
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A computer system includes a data storage module. The data storage module receives, stores, and provides access to data related to long term disability claims. A proactive referral model component is coupled to the data storage module, and determines whether to refer a current claim to an investigation unit. The proactive referral model is based on at least two of the following variables: (a) a variable that indicates that the claimant'"'"'s diagnosis has changed; (b) a variable that indicates that the current claim in question was brought under any-occupation coverage; (c) a variable that reflects a market segment for a policy under which the current claim in question was brought; (d) a variable that has a value based on a state in which the claimant resides; and (e) a variable that represents an amount of experience of a claims handler who handled the current claim in question.

Claims

1. A computer system comprising:

a data storage module for receiving, storing, and providing access to claim data, the claim data representing historical and current long term disability claims;

a proactive referral model component, coupled to the data storage module, for determining whether to identify a one of said current claims for referral to an investigation unit, said proactive referral model based on a plurality of variables, the variables including at least one of;

(a) a variable that indicates that a claimant'"'"'s diagnosis has changed;

(b) a variable that indicates that the one of said current claims was brought under any-occupation coverage;

(c) a variable that reflects a market segment for a policy under which the one of said current claims was brought;

(d) a variable that has a value based on a state in which the claimant resides; and

(e) a variable that represents an amount of experience of a claims handler who handled the one of said current claims;

a computer processor for executing programmed instructions and for storing and retrieving said data related to current claims;

program memory, coupled to the computer processor, for storing program instruction steps for execution by the computer processor;

a model training component, coupled to the computer processor, for training the proactive referral model component based on the data related to the historical claims in accordance with program instructions stored in the program memory and executed by the computer processor, thereby providing a trained proactive referral model component;

an output device, coupled to the computer processor, for outputting an output indicative of whether said one of said current claims 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 application of data for said one of said current claims to the trained proactive referral model component; and

a routing module for directing workflow based on the output from the output device.

2. The computer system of claim 1, wherein the routing module routes said one of the current claims to the investigation unit based on the output from the output device.

3. The computer system of claim 2, wherein the routing module routes said one of the current claims to an investigative analyst in the investigation unit.

4. The computer system of claim 1, wherein said at least one variable indicates that a claimant'"'"'s diagnosis has changed.

5. The computer system of claim 1, wherein the proactive referral model component was built using multiple linear regression.

6. The computer system of claim 1, wherein the proactive referral model component was built using backward regression variable selection.

7. A computer system comprising:

a data storage unit for receiving, storing and providing access to historical claim data and current claim data, the historical claim data representing historical long term disability (LTD) claims, the current claim data representing current LTD claims;

a computer processor in communication with the data storage unit; and

a program memory, coupled to the computer processor, for storing at least one application program, the at least one application program including program instruction steps for execution by the computer processor, the at least one application program including;

a proactive referral model that has been trained on and verified with the historical claim data and that controls the computer processor to analyze the current claim data in the data storage unit and to provide a respective output for each current claim represented by the current claim data, the respective output indicating whether said each current claim should be referred to an investigation unit; and

a routing component, responsive to the respective output for each of the current claims, for selectively routing ones of the current claims to the investigation unit;

wherein said proactive referral model is based on a plurality of variables, the variables including at least one of;

(a) a variable that indicates that a claimant'"'"'s diagnosis has changed;

(b) a variable that indicates that the one of said current claims was brought under any-occupation coverage;

(c) a variable that reflects a market segment for a policy under which the one of said current claims was brought;

(d) a variable that has a value based on a state in which the claimant resides; and

(e) a variable that represents an amount of experience of a claims handler who handled the one of said current claims.

8. The computer system of claim 7, wherein the computer processor, under control by the routing component, routes ones of the current claims via electronic mail messages to the investigation unit.

9. The computer system of claim 8, wherein investigative analysts in the investigation unit are recipients of the electronic mail messages.

10. The computer system of claim 7, wherein the at least one application program includes:

a data extraction component for controlling the computer processor to extract information from text files.

11. The computer system of claim 7, wherein the data storage unit includes a data warehouse.

12. The computer system of claim 7, wherein said at least one variable indicates said current claim'"'"'s characteristics.

13. The computer system of claim 7, wherein said at least one variable indicates said current claim'"'"'s associated policy characteristics.

14. A computer system comprising:

a data storage module for receiving, storing, and providing access to claim data, the claim data representing historical and current long term disability claims;

a proactive referral model component, coupled to the data storage module, for determining whether to identify a one of said current claims for referral to an investigation unit, said proactive referral model based on a plurality of variables;

a computer processor for executing programmed instructions and for storing and retrieving said data related to current claims;

program memory, coupled to the computer processor, for storing program instruction steps for execution by the computer processor;

a model training component, coupled to the computer processor, for training the proactive referral model component based on the data related to the historical claims in accordance with program instructions stored in the program memory and executed by the computer processor, thereby providing a trained proactive referral model component;

an output device, coupled to the computer processor, for outputting an output indicative of whether said one of said current claims 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 application of data for said one of said current claims to the trained proactive referral model component; and

a routing module for directing workflow based on the output from the output device.

15. The computer system of claim 14, wherein the routing module routes said one of the current claims to the investigation unit based on the output from the output device.

16. The computer system of claim 15, wherein the routing module routes said one of the current claims to an investigative analyst in the investigation unit.

17. The computer system of claim 14, wherein the data storage module includes a data warehouse.

18. The computer system of claim 14, wherein the proactive referral model component was built using multiple linear regression.

19. The computer system of claim 14, wherein the proactive referral model component was built using backward regression variable selection.

20. The computer system of claim 14, wherein at least one of the variables is indicative of:

(a) a geographical state in which the claimant resides being a state that has a high rate of questionable disability claims;

(b) the geographical state in which the claimant resides being a state that has a low rate of questionable disability claims;

(c) the claimant'"'"'s diagnosis code being one which exhibits a high rate of questionable disability claims;

(d) a change in the claimant'"'"'s diagnosis;

(e) an amount of experience of the claims handler;

(f) the claim having been brought under any-occupation coverage;

(g) whether the claimant has been classified as disabled for purposes of Social Security benefits;

(h) whether the claimant'"'"'s occupation was classified as sedentary;

(i) the market segment for the policy under which the claim was brought;

(j) whether the claimant'"'"'s diagnosis code was in a subcategory that was highly likely to experience questionable claims;

(k) the claimant'"'"'s employer having an SIC (standard industrial classification) code that is highly likely to experience questionable claims; and

(l) the duration of the claim.

21. The computer system of claim 14, wherein the variables comprise claim geographic related data and claim characteristic data.