AUTOMATION OF AUDITING CLAIMS

• US 20130173313A1
• Filed: 02/27/2013
• Published: 07/04/2013
• Est. Priority Date: 05/29/2009
• Status: Active Grant

• Current Assignee: HyperQuest, Inc. (Solera Holdings Incorporated)
• Original Assignee: HyperQuest, Inc. (Solera Holdings Incorporated)
• Inventors: Hogan, Dennis M., Hogan, Jeffrey J.
• Granted Patent: US 8,781,863 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 30/0222 During e-commerce, i.e. online transactions
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Described are computer-based methods and apparatuses, including computer program products, for automation of auditing claims. A data file is received comprising one or more auditable items, each auditable item comprising a word string having one or more words. Each word string for each auditable item is translated using one or more translation steps into a translated item description. Each translated item description is compared to a plurality of terms to generate matching information. Each translated item description is associated with an item identifier based on the matching information. Each auditable item is accepted or rejected based on the item identifier and one or more rules associated with the data file.

Claims

1-28. -28. (canceled)

29. A computerized auditing method comprising:

receiving, via a processor, a data file comprising one or more auditable items;

extracting, using the processor, a word string from each auditable item;

translating, using the processor, each word string using one or more translation steps into a translated item description;

for each translated item description;

comparing, using the processor, the translated item description to a plurality of terms;

generating, using the processor, a matching table comprising one or more entries, wherein each entry of the matching table comprises a matching term from the plurality of terms and matching information, the matching information comprising a match characteristic between the translated item description and the term and an item identifier;

determining, using the processor, whether the match characteristic for each entry is below a predetermined threshold;

if the match characteristic is below the predetermined threshold, removing, using the processor, the entry from the matching table;

determining, using the processor, if one entry of the matching table comprises a best match;

if one entry comprises the best match, associating, using the processor, the item identifier of the one entry with the translated item description;

if no entry comprises the best match;

determining, using the processor, whether a plurality of entries comprise a similar match indicator value; and

if the plurality of entries comprise the similar match indicator value, associating, using the processor, the item identifier for each of the plurality of entries with the translated item description, otherwise associating the translated item description with a no match indicator;

accepting, using the processor, or rejecting each auditable item associated with an item identifier based on the item identifier and one or more rules associated with the data file; and

generating, using the processor, an audit report.

30. A computerized auditing method comprising:

receiving, via a processor, a data file comprising one or more auditable items, each auditable item comprising a word string having one or more words;

translating, using the processor, each word string into a translated item description, wherein translating comprises;

determining, using the processor, whether the word string comprises a primary name;

if the word string comprises a primary item name, calculating, using the processor, the translated item description based on the primary name; and

if the word string does not comprise a primary item name, calculating, using the processor, the translated item description based on the last word of the word string;

comparing, using the processor, each translated item description to a plurality of predetermined terms to generate matching information;

associating, using the processor, each translated item description with an item identifier based on the matching information; and

accepting, using the processor, or rejecting each auditable item based on the item identifier and one or more rules associated with the data file.

31. A computerized auditing method comprising:

receiving, using the processor, a data file comprising one or more auditable items, each auditable item comprising a word string having one or more words;

translating, using the processor, each word string for each auditable item into a translated item description, wherein translating each word string comprises;

generating, using the processor, relationship information between two or more words of the word string based on a classification of each word of the word string;

determining, using the processor, whether each word of the word string is associated with the relationship information;

if each word of the word string is associated with the relationship information, calculate, using the processor, the translated item description based on the relationship information; and

if each word of the word string is not associated with the relationship information, calculate, using the processor, the translated item description based on ordering information;

comparing, using the processor, each translated item description to a plurality of predetermined terms to generate matching information;

associating, using the processor, each translated item description with an item identifier based on the matching information; and

accepting, using the processor, or rejecting each auditable item based on the item identifier and one or more rules associated with the data file.

32. A apparatus comprising:

an auditing system configured to receive a data file comprising one or more auditable items, each auditable item comprising a word string having one or more words; and

a translator in communication with the auditing apparatus configured to;

translate each word string for each auditable item using one or more translation steps into a translated item description;

compare each translated item description to a plurality of terms to generate matching information;

associate each translated item description with an item identifier based on the matching information; and

accept or reject each auditable item based on the item identifier and one or more rules associated with the data file.

33. The apparatus of claim 32 further comprising a text recognition unit in communication with the audit unit and the translator configured to recognize the text of the data file.

34. The apparatus of claim 32 further comprising an output unit configured to generate an audit report, the audit report comprising an audit result for each auditable item of the data file.

35. The apparatus of claim 32 further comprising a database in communication with the translator configured to store one or more rules, the one or more rules being used to translate the word string.

36. A computer program product, tangibly embodied in a computer readable storage medium, the computer program product including instructions being operable to cause a data processing apparatus to:

receive a data file comprising one or more auditable items, each auditable item comprising a word string having one or more words;

translate each word string for each auditable item using one or more translation steps into a translated item description;

compare each translated item description to a plurality of terms to generate matching information;

associate each translated item description with an item identifier based on the matching information; and

accept or rejecting each auditable item based on the item identifier and one or more rules associated with the data file.

37. An apparatus comprising:

means for receiving a data file comprising one or more auditable items, each auditable item comprising a word string having one or more words;

means for;

translating each word string for each auditable item using one or more translation steps into a translated item description;

comparing each translated item description to a plurality of terms to generate matching information;

associating each translated item description with an item identifier based on the matching information; and

accepting or rejecting each auditable item based on the item identifier and one or more rules associated with the data file.

39. A computerized auditing method comprising:

translating, using a processor, a word string of an auditable item using one or more translation steps into a translated item description, wherein the auditable item is a line item from an insurance claim file; and

using the processor, accepting or rejecting the auditable item based on the translating, wherein the accepting includes automatically approving part selections on behalf of an insurer.

50. The method of claim 39, wherein the accepting includes documenting historical parts availability for subrogation reviewers.

40. A computerized auditing method comprising:

receiving, via a processor, a data file comprising one or more auditable items, each auditable item being a line item from an insurance claim file, where each auditable item comprises a word string having one or more words;

translating, using the processor, each word string for each auditable item using one or more translation steps into a translated item description, including automatically translating an operational item from the one or more auditable items, the operational item being an auditable item that does not involve a physical removal of a vehicle part or replacement of a vehicle part with a replacement part;

associating, using the processor, each translated item description with an item identifier; and

using the processor, accepting or rejecting each auditable item based on the item identifier and one or more rules associated with the data file.

41. The method of claim 40, wherein the data file is associated with a subrogation demand.

47. The method of claim 40, wherein the insurance claim file includes a demand for subrogation.

42. A computerized auditing method comprising:

receiving, via a processor, an insurance data file comprising one or more auditable items, each auditable item comprising a word string having one or more words;

translating, using the processor, each word string for each auditable item using one or more translation steps into a translated item description, including automatically translating an operational item from the one or more auditable items, the operational item being an auditable item that does not involve replacement of a vehicle part with a replacement part;

associating, using the processor, each translated item description with an item identifier; and

using the processor, accepting an auditable item based on the item identifier and one or more rules associated with the data file.

43. The method of claim 42, wherein the data file is associated with a subrogation demand.

44. A computerized vehicle insurance auditing system comprising:

a processor coupled to a nontransitory computer readable storage medium having stored therein software instructions that, when executed by the processor, cause the processor to perform a series of operations including;

receiving, via the processor, a data file comprising one or more auditable items, each auditable item being a line item from an insurance claim file, each auditable item comprising a word string having one or more words;

translating, using the processor, each word string for each auditable item using one or more translation steps into a translated item description;

associating, using the processor, each translated item description with an item identifier; and

using the processor, automatically determining whether to accept or reject each auditable item based on the item identifier and one or more rules associated with the data file.

48. The system of claim 44, wherein the insurance claim file includes a demand for subrogation.

45. A nontransitory computer readable storage medium having stored therein software instructions that, when executed by a processor, cause the processor to perform a series of operations including:

receiving an insurance data file comprising one or more auditable items, each auditable item comprising a word string having one or more words;

translating each word string for each auditable item using one or more translation steps into a translated item description;

comparing each translated item description to a plurality of terms to generate matching information;

associating each translated item description with an item identifier based on the matching information; and

determining whether to accept or reject each auditable item based on the item identifier and one or more rules associated with the data file.

49. The medium of claim 45, wherein the insurance claim file includes a demand for subrogation.