PREDICTIVE MODELING PROCESSES FOR HEALTHCARE FRAUD DETECTION
First Claim
1. A method, comprising:
- receiving, by one or more devices of a healthcare fraud management system, healthcare claims;
performing, by the one or more devices, data reduction on information associated with the healthcare claims;
processing, by the one or more devices, the reduced information associated with the healthcare claims by using a plurality of rules;
generating, by the one or more devices, alarms, for the healthcare claims, based on the processing of the reduced information associated with the healthcare claims;
generating, by the one or more devices, scores for the alarms based on one or more predictive modeling tools;
prioritizing, by the one or more devices, the healthcare claims, to create a list of prioritized healthcare claims, based on the generated scores for the alarms corresponding to the healthcare claims; and
outputting, by the one or more devices and prior to payment of the healthcare claims, the list of the prioritized healthcare claims to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claims.
1 Assignment
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Accused Products
Abstract
A healthcare fraud management system receives healthcare claims, performs data reduction on information associated with the healthcare claims, and processes the reduced information associated with the healthcare claims by using a plurality of rules. The system also generates alarms, for the healthcare claims, based on the processing of the reduced information associated with the healthcare claims, generates scores for the alarms based on one or more predictive modeling rules, and prioritizes the healthcare claims, to create a list of prioritized healthcare claims, based on the generated scores for the alarms corresponding to the healthcare claims. The system further outputs, prior to payment of the healthcare claims, the list of the prioritized healthcare claims to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claims.
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Citations
26 Claims
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1. A method, comprising:
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receiving, by one or more devices of a healthcare fraud management system, healthcare claims; performing, by the one or more devices, data reduction on information associated with the healthcare claims; processing, by the one or more devices, the reduced information associated with the healthcare claims by using a plurality of rules; generating, by the one or more devices, alarms, for the healthcare claims, based on the processing of the reduced information associated with the healthcare claims; generating, by the one or more devices, scores for the alarms based on one or more predictive modeling tools; prioritizing, by the one or more devices, the healthcare claims, to create a list of prioritized healthcare claims, based on the generated scores for the alarms corresponding to the healthcare claims; and outputting, by the one or more devices and prior to payment of the healthcare claims, the list of the prioritized healthcare claims to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claims. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8)
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9. A system, comprising:
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one or more memory devices to store a plurality of rules for detecting healthcare fraud; and one or more processors to; receive healthcare claims, perform data reduction on information associated with the healthcare claims, process the reduced information associated with the healthcare claims by using the plurality of rules, generate alarms, for the healthcare claims, based on the processing of the reduced information associated with the healthcare claims, generate scores for the alarms based on one or more predictive modeling rules, prioritize the healthcare claims, to create a list of prioritized healthcare claims, based on the generated scores for the alarms corresponding to the healthcare claims, and output, prior to payment of the healthcare claims, the list of the prioritized healthcare claims to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claims. - View Dependent Claims (10, 11, 12, 13, 14, 15, 16, 17, 18)
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19. A computer-readable medium, comprising:
one or more instructions that, when executed by at least one processor of a healthcare fraud management system, cause the at least one processor to; receive healthcare claims, perform data reduction on information associated with the healthcare claims, process the reduced information associated with the healthcare claims by using a plurality of rules, generate alarms, for the healthcare claims, based on the processing of the reduced information associated with the healthcare claims, generate scores for the alarms based on one or more predictive modeling rules, prioritize the healthcare claims, to create a list of prioritized healthcare claims, based on the generated scores for the alarms corresponding to the healthcare claims, and output, prior to payment of the healthcare claims, the list of the prioritized healthcare claims to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claims. - View Dependent Claims (20, 21, 22, 23, 24, 25, 26)
Specification