Insurance claim forecasting system
First Claim
1. A computer-implemented process for developing models for forecasting future person-level health care costs for use in underwriting health insurance comprising the steps of:
- storing in a computer readable memory historical health care claims data and enrollment data for a plurality of people for each of a base period and a next period separated by a lag period, where the person-level health care claims data comprise at least a claim code and a claim amount;
programming a computer processor associated the computer readable memory with risk factor definitions that assign risk factors;
processing with the programmed computer processor the base period health care claims data and enrollment data to for each of the plurality of people to assign at least one claim based risk factor from the base period claim codes and at least one enrollment based risk factor from the base period enrollment data;
storing the risk factors assigned to each of the plurality of people in the computer readable memory;
programming a computer processor associated with the computer readable memory with at least one interaction capturing technique;
processing with the programmed computer processor the risk factors assigned to the plurality of people with the interaction capturing technique to determine the ability of individual risk factors and combinations of risk factors to forecast the health care costs associated with the plurality of people in the next period;
storing the determined abilities in the computer readable memory;
programming a computer processor associated with the computer readable memory to select a plurality of risk factors having the greatest ability to forecast next period person-level health care costs;
storing the selected risk factors; and
processing with the computer processor selected risk factors to generate a model comprising a combination of the selected base period risk factors and the associated logical and mathematical operations that when applied to those risk factors predicts person-level health care costs in the next period.
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Accused Products
Abstract
A computer-implemented process of developing a person-level cost model for forecasting future costs attributable to claims from members of a book of business, where person-level data are available for a substantial portion of the members of the book of business for an actual underwriting period, and the forecast of interest is for a policy period is disclosed. The process uses development universe data comprising person-level enrollment data, historical base period health care claims data and historical next period claim amount data for a statistically meaningful number of individuals. The process also provides at least one claim-based risk factor for each historical base period claim based on the claim code associated with the health care claim and provides at least one enrollment-based risk factor based on the enrollment data. The process also develops a cost forecasting model by capturing the predictive ability of the main effects and interactions of claim based risk factors and enrollment-based risk factors, with the development universe data through the application of an interaction capturing technique to the development universe data.
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Citations
47 Claims
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1. A computer-implemented process for developing models for forecasting future person-level health care costs for use in underwriting health insurance comprising the steps of:
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storing in a computer readable memory historical health care claims data and enrollment data for a plurality of people for each of a base period and a next period separated by a lag period, where the person-level health care claims data comprise at least a claim code and a claim amount; programming a computer processor associated the computer readable memory with risk factor definitions that assign risk factors; processing with the programmed computer processor the base period health care claims data and enrollment data to for each of the plurality of people to assign at least one claim based risk factor from the base period claim codes and at least one enrollment based risk factor from the base period enrollment data; storing the risk factors assigned to each of the plurality of people in the computer readable memory; programming a computer processor associated with the computer readable memory with at least one interaction capturing technique; processing with the programmed computer processor the risk factors assigned to the plurality of people with the interaction capturing technique to determine the ability of individual risk factors and combinations of risk factors to forecast the health care costs associated with the plurality of people in the next period; storing the determined abilities in the computer readable memory; programming a computer processor associated with the computer readable memory to select a plurality of risk factors having the greatest ability to forecast next period person-level health care costs; storing the selected risk factors; and processing with the computer processor selected risk factors to generate a model comprising a combination of the selected base period risk factors and the associated logical and mathematical operations that when applied to those risk factors predicts person-level health care costs in the next period. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16)
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17. A computer-implemented process of forecasting a claim amount attributable to claims from members of a book of business during an actual policy period, comprising the steps of:
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storing in a computer readable memory person-level data, comprising enrollment data for members of a book of business to be insured for an actual underwriting period that is not contiguous with the actual policy period; storing in a computer readable memory a model development universe of person-level data, comprising enrollment data from the historical base period and historical next period heath care claims data for a plurality of individuals; storing in a computer readable memory enrollment-based risk factors for each historical base period member and next period claim amounts for each historical base period member; programming a computer processor associated with the computer readable memory with an interaction capturing technique; processing the risk factors with the computer processor to capture the predictive ability of main effects and interactions of the enrollment-based risk factors through the application of the interaction capturing technique to the model development universe; storing in the computer readable memory the predictive ability of the main effects and interactions of the enrollment-based risk factors; programming a computer processor associated with the compute readable memory to generate a person-level cost forecast by applying the predictive ability of the main effects and interactions of the enrollment-based risk factors; processing with the computer processor the person-level underwriting period enrollment data of each of the members of the book of business to generate a person-level expected cost forecast for the policy period for each member of the book of business; storing in the computer readable memory the person-level costs forecasts; programming a computer processor associated with the computer readable memory to total the person-level cost forecasts; and processing with the computer processor to total the person-level forecasts of each person of the group produce a group-level forecast for the expected cost of the policy period.
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18. A computer-implemented process of forecasting costs attributable to claims from members of a book of business during an actual policy period, comprising the steps of:
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storing in a computer readable memory person-level data, comprising enrollment data and actual underwriting period health care claims data, for members of a book of business, where the person-level data on a health care claim comprises at least a claim amount and a claim code and the actual underwriting period is not contiguous with the actual policy period; storing in a computer readable memory a model development universe of person-level data, comprising enrollment data, historical base period health care claims data and historical next period claim data for a plurality of individuals, where the person-level data on a base period health care claim includes at least a claim amount and a claim code; storing in a computer readable memory claim-based risk factors for each historical base period based on the claim code associated with the health care claim and providing at least one enrollment risk factor based on the enrollment data; programming a computer processor associated with the computer readable memory with an interaction capturing technique; processing the model development universe to develop a cost-forecasting model by capturing the predictive ability of main effects and interactions of risk factors through the application of the interaction capturing technique; storing the cost forecasting model in the computer readable memory; programming a computer processor associated with the computer readable memory to apply the cost-forecasting model to the person-level data of each of the individuals or members of a group to generate a person-level actual policy period expected cost forecast for each member of the group; and processing with the computer processor the person-level forecasts of each individual or member of the group to produce a group-level forecast for the actual policy period by totaling the person-level cost forecasts for the actual policy period. - View Dependent Claims (19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32)
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33. An automated system for forecasting future costs attributable to claims from members of a book of business during an actual policy period comprising:
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a central processing unit; an insured person database, accessible by the processing unit, wherein the database comprises person-level enrollment data and actual underwriting period health care claims data, for members of a book of business to be insured, where the person-level data on a health care claim comprises at least a claim amount and a claim code; a model development universe database, accessible by the processing unit, where the second database comprises model development universe of person-level data, comprising enrollment data, historical base period health care claims data and historical next period claim amount data for a plurality of individuals, where the person-level data on the base period health care claim includes at least a claim amount and a claim code; a risk factor encoder, accessible by the processing unit, wherein the risk factor encoder encodes claim-based risk factors for each historical base period claim based on the claim code associated with the health care claim and the risk factor encoder encodes at least one enrollment risk factor based on the enrollment data; a model generator, accessible by the processing unit, that generates a cost-forecasting model by capturing the predictive capacity of the main effects and the interaction of the risk factors assigned by the risk factor encoder to forecast the historical next period of the model development universe data using the historical base period data; a person-level cost generator that applies the cost-forecasting model to the person-level actual underwriting period health care claims data of each of the members of the book of business to generate a person-level actual policy period claim amount forecast for each member of the book of business; and an actual policy period group-level cost forecast generator that totals the person-level actual next period forecasts for each member of the group to generate an actual policy period group-level cost forecast. - View Dependent Claims (34)
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35. A computer-implemented system of forecasting costs attributable to claims from members of a book of business during an actual policy period, comprising:
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means for providing person-level data, comprising enrollment data and actual underwriting period health care claims data, for members of a book of business, where the person-level data on a health care claim comprises at least a claim amount and a claim code and the actual underwriting period is not contiguous with the actual policy period; means for providing a model development universe of person-level data, comprising enrollment data, historical base period health care claims data and historical next period claim amount data for a plurality of individuals, where the person-level data on a base period health care claim includes at least a claim amount and a claim code; means for providing claim-based risk factors for each historical base period based on the claim code associated with the health care claim and providing at least one enrollment risk factor based on the enrollment data; means for developing a cost-forecasting model by capturing the predictive ability of main effects and interactions of risk factors through the application of an interaction capturing technique to the model development universe; means for applying the cost-forecasting model to the person-level data of each of the individuals or members of a group to generate a person-level actual policy period expected cost forecast for each member of the group; and means for producing a group-level forecast for the actual policy period from the person-level forecasts of each individual or member of the group by totaling the person-level cost forecasts for the actual policy period. - View Dependent Claims (36, 37)
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38. A method of underwriting a health insurance product comprising the steps of
storing in a computer readable memory an identification of the coverage of the insurance product which identifies the conditions of payment under the product during a policy period; -
storing in a computer readable memory person-level health care claim information comprising enrollment data, and base period, next period and underwriting period claim data, the claim data comprising claim codes having associated claim costs; programming a computer processor associated with the computer readable memory with an interaction capturing technique; processing the person-level health care claim information with the interaction capturing technique to capture the predictive ability of the person-level health care claim and eligibility information; storing the captured predictive ability of the person-level health care claim information programming a computer processor to forecast a predicted cost of the insurance product; and processing with the computer processor the identification of the coverage of the insurance product and the captured predictive ability of the person-level health care claim and eligibility information to forecast a predicted cost of the insurance product during the policy period. - View Dependent Claims (39, 40, 41, 42, 43, 44, 45, 46, 47)
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Specification