INSURANCE CLAIMS PROCESSING

• US 20130226623A1
• Filed: 02/22/2013
• Published: 08/29/2013
• Est. Priority Date: 02/24/2012
• Status: Active Grant

• Current Assignee: TATA Consultancy Services Limited (Tata Sons Pvt Ltd.)
• Original Assignee: TATA Consultancy Services Limited (Tata Sons Pvt Ltd.)
• Inventors: Diana, Frank, Mulcahy, Kevin, Menkin, Gary, Bhargava, Ajay, Gupta, Ruchi, Bhattacharyya, Tumpa
• Granted Patent: US 9,299,108 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 40/08 Insurance

Abstract

Systems and methods for insurance claims processing in an insurance industry are described. The method comprises combining extracted claims data from one or more data sources to obtain a consolidated claims record and removing noise from text data of the consolidated claims record to obtain a claim dataset. The claims data comprises a plurality of claims. Further, ascertaining one or more suspicion indicators in the plurality of claims based on an analytical technique. Further, assigning a score to each of the plurality of claims based on at least one scoring rule. The score is an indicative of a level of suspicion of a claim. Furthermore, detecting at least one of insurance claims fraud and subrogation potential claims based on the score assigned to each of the plurality of claims.

Claims

1. An insurance claims processing system for insurance claims processing, the insurance claims processing system comprising:

a processor;

an analysis module coupled to the processor, the analysis module configured to ascertain one or more suspicion indicators in a plurality of claims based on an analytical technique; and

a scoring module coupled to the processor, the scoring module configured to;

assign a score to each of the plurality of claims based on at least one scoring rule comprising one or more scoring parameters, wherein the score is indicative of a level of suspicion of a claim; and

identifying at least one of insurance claims fraud and subrogation potential claims based on the score assigned to each of the plurality of claims.

2. The insurance claims processing system as claimed in claim 1 further comprising a data acquisition module coupled to the processor, the data acquisition module configured to:

extract claims data from one or more data source;

combine the claims data to obtain a consolidated claims record having text data; and

remove noise from the text data of the consolidated claims records to obtain a claim dataset, wherein the claim dataset includes the plurality of claims.

3. The insurance claims processing system as claimed in claim 1, wherein the analytic technique is at least one of a text analysis, a predictive model analysis, a link analysis, a business rules analysis, and a social-media analysis.

4. The insurance claims processing system as claimed in claim 1, wherein the scoring module is configured to create the at least one scoring rule for a specific client and a line of business (LOB).

5. The insurance claims processing system as claimed in claim 1, wherein the one or more suspicion indicators are obtained from a dictionary, and wherein the dictionary includes concepts for identifying the suspicious claim.

6. The insurance claims processing system as claimed in claim 1, wherein the scoring module is configured to update the dictionary based on a line of business (LOB).

7. The insurance claims processing system as claimed in claim 1, wherein the scoring module is configured to recalculate the score upon receiving new information related to the plurality of claims.

8. The insurance claims processing system as claimed in claim 1, wherein the scoring module is configured to categorize the plurality of claims into one or more categories based on the score assigned to each of the plurality of claims.

9. The insurance claims processing system as claimed in claim 1 further comprising a workbench module coupled to the processor, the workbench module is configured to generate reports having the claims data.

10. The insurance claims processing system as claimed in claim 1, wherein the workbench module is configured to illustrate the one or more suspicion indictors in the plurality of claims upon receiving a drill down request from a fraud analyst.

11. A method for insurance claims processing in an insurance industry, the method comprising:

extracting claims data from one or more data sources;

combining the claims data to obtain a consolidated claims record having text data;

removing noise from the text data of the consolidated claims records to obtain a claim dataset, wherein the claim dataset includes a plurality of claims;

ascertaining one or more suspicion indictors in the plurality of claims based on an analytical technique;

assigning a score to each of the plurality of claims based on at least one scoring rule comprising one or more scoring parameters, wherein the score is an indicative of a level of suspicion of a claim; and

identifying at least one of insurance claims fraud and subrogation potential claims based on the score assigned to each of the plurality of claims.

12. The method as claimed in claim 11, wherein the one or more sources include at least one of internal and external data storage systems in an insurance organization, imaged content which contains photos and scanned copies of claim related information, speech content, and web content.

13. The method as claimed in claim 11, wherein the analytical technique is at least one of a text analysis, a predictive model analysis, a link analysis, business rules analysis, and a social-media analysis.

14. The method as claimed in claim 11 wherein the at least one scoring rule is created specific to a client and a line of business (LOB).

15. The method as claimed in claim 11, wherein the scoring parameters are a combination of at least one of rule name, client, line of business (LOB), suspicion indicators, claim filtration criteria, and claims funnel.

16. A computer-readable medium having embodied thereon a computer program for executing a method of insurance claims processing in an insurance industry, the method comprising:

extracting claims data from one or more data sources;

combining the claims data to obtain a consolidated claims record having text data;

removing noise from the text data of the consolidated claims records to obtain a claim dataset, wherein the claim dataset includes a plurality of claims;

ascertaining one or more suspicion indictors in the plurality of claims based on an analytical technique;

assigning a score to each of the plurality of claims based on at least one scoring rule comprising one or more scoring parameters, wherein the score is an indicative of a level of suspicion of a claim; and

identifying at least one of insurance claims fraud and subrogation potential claims based on the score assigned to each of the plurality of claims.

17. The computer readable medium as claimed in claim 16, wherein the at least one scoring rule is created for a specific client and line of business (LOB).

18. The computer readable medium as claimed in claim 16, the scoring parameters are a combination of at least one of rule name, client, line of business (LOB), suspicion indicators, claim filtration criteria, and claims funnel.

19. The computer readable medium as claimed in claim 16, the score is recalculated upon receiving new information related to the plurality of claims.

20. The computer readable medium as claimed in claim 16, wherein the plurality of claims are categorized into one or more categories based on the score assigned to each of the plurality of claims.