Rule-based Prediction of Medical Claims' Payments
First Claim
1. ) A non-transitory computer readable medium including a series of computer readable instructions configured to cause one or more processors to execute a method comprising:
- a) generating a prediction employing a machine learning engine executing on the one or more processors, the prediction forecasting if first patient claim data when submitted to a payer will result in at least one of the following;
i) an approved submission;
ii) a denied submission; and
iii) an apparent payment variation; and
b) updating the machine learning engine using the prediction; and
wherein the machine learning engine is trained by;
i) generating labeled data by classifying at least one second patient claim data residing in a database of claim records and histories with at least one of the following;
(1) an anomaly detection label;
(2) a contract based label; and
(3) a combination of the above;
ii) employing the labeled data to train a claims classification model; and
iii) creating a predictive paid amount model employing at least one of the following;
(1) the labeled data;
(2) an amount paid on a claim; and
(3) a combination of the above.
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Abstract
Some embodiments of the present invention evaluate claim submissions. Prediction(s) are generated that employ machine learning engine(s) and/or expert models executing on processor(s). The prediction(s) may forecast if claim data when submitted to a payer will result in at least one of the following: an approved submission; a denied submission; and an apparent payment variation. The machine learning engine(s) may be updated using use the prediction. Labeled data may be generated by classifying patient claim data residing in a database of claim records and histories with at least one of the following: an anomaly detection label; a contract based label; and a combination of the above. Claims classification model(s) may be trained using the labeled data. Predictive paid amount model(s) may be created that employ at least the labeled data and/or an amount paid on a claim.
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Citations
20 Claims
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1. ) A non-transitory computer readable medium including a series of computer readable instructions configured to cause one or more processors to execute a method comprising:
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a) generating a prediction employing a machine learning engine executing on the one or more processors, the prediction forecasting if first patient claim data when submitted to a payer will result in at least one of the following; i) an approved submission; ii) a denied submission; and iii) an apparent payment variation; and b) updating the machine learning engine using the prediction; and wherein the machine learning engine is trained by; i) generating labeled data by classifying at least one second patient claim data residing in a database of claim records and histories with at least one of the following; (1) an anomaly detection label; (2) a contract based label; and (3) a combination of the above; ii) employing the labeled data to train a claims classification model; and iii) creating a predictive paid amount model employing at least one of the following; (1) the labeled data; (2) an amount paid on a claim; and (3) a combination of the above. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16)
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17. ) A method comprising:
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a) generating a prediction employing a machine learning engine executing on one or more processors, the prediction forecasting if first patient claim data when submitted to a payer will result in at least one of the following; i) an approved submission; ii) a denied submission; and iii) an apparent payment variation; and b) updating the machine learning engine using the prediction; and wherein the machine learning engine is trained by; i) generating labeled data by classifying at least one second patient claim data residing in a database of claim records and histories with at least one of the following; (1) an anomaly detection label; (2) a contract based label; and (3) a combination of the above; ii) employing the labeled data to train a claims classification model; and iii) creating a predictive paid amount model employing at least one of the following; (1) the labeled data; (2) an amount paid on a claim; and (3) a combination of the above.
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18. ) A non-transitory computer readable medium including a series of computer readable modules configured to cause one or more processors to execute a method, the modules comprising:
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a) a payer-specific screening module configured to cause the one or more processors to generate a prediction employing a payer-specific machine learning engine and a payer-specific expert model, the prediction forecasting if first patient claim data when submitted to a payer will result in at least one of the following; i) an approved submission; ii) a denied submission; and iii) an apparent payment variation; and b) an update module configured to update the payer-specific machine learning engine using the prediction; and wherein the payer-specific machine learning engine is trained by; i) generating payer-specific labeled data by classifying at least one second patient claim data residing in a database of claim records and histories with at least one of the following; (1) a payer-specific anomaly detection label; (2) a payer-specific contract based label; and (3) a combination of the above; ii) employing the labeled data to train a claims classification model; and iii) creating a payer-specific predictive paid amount model employing at least one of the following; (1) the payer-specific labeled data; (2) a payer-specific amount paid on a claim; and (3) a combination of the above. - View Dependent Claims (19, 20)
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Specification