System and method for processing insurance claims

• US 7,739,133 B1
• Filed: 03/02/2004
• Issued: 06/15/2010
• Est. Priority Date: 03/03/2003
• Status: Active Grant

• Current Assignee: Equian, LLC (UnitedHealth Group Incorporated)
• Original Assignee: Trover Solutions, Inc. (UnitedHealth Group Incorporated)
• Inventors: Bates, Mark, Hail, Mitzi R.
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): LE, LINH GIANG
• Application Number:
  US10/790,145
• Time in Patent Office: 2,296 Days
• Field of Search: 705 2- 4, 715/260
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Systems consistent with the present invention automatically process data associated with insurance claims to identify insurance claims with subrogation potential. Text from an insurance claim file may be automatically analyzed to extract data that can be quantified to determine whether the claim may have subrogation potential.

Claims

1. A computer-implemented method for processing insurance claims in a computer system having a plurality of software components, the method comprising:

providing a processor and a memory storing computer readable code accessible by the processor for processing the insurance claims, the computer readable code comprising a text analyzer, a rules engine, and a score analyzer, and

executing the computer readable code by the processor to perform;

identifying, by the text analyzer using a specialized insurance dictionary, insurance data elements in text associated with an insurance claim;

extracting, by the text analyzer, the insurance data elements related to the insurance claim'"'"'s subrogation potential, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups;

storing, by the text analyzer, the extracted insurance data elements in data tables corresponding to the insurance claim;

developing a subrogation potential score by the rules engine for each of the insurance data elements, wherein the developing further comprises;

calculating the subrogation potential score using a set of rules created from existing historical claim data, or

assigning the subrogation potential score using the set of rules; and

determining, by the score analyzer, if the insurance claim has subrogation potential based on the subrogation potential scores developed for each of the insurance data elements.

2. The computer-implemented method of claim 1, wherein the identifying further comprises:

separating the text into words;

collecting the words into groups; and

parsing the groups into the insurance data elements.

3. The computer-implemented method of claim 2, wherein the groups are non-sentence groupings.

4. The computer-implemented method of claim 2, wherein the groups are sentences.

5. A computer-implemented method for processing an insurance claim in a computer system having a plurality of software modules, the method comprising:

providing a processor and a memory storing computer readable code accessible by the processor for processing the insurance claim, the computer readable code comprising a receiving module, a separating module, a text analyzer, an assigning module, and an evaluating module, and

executing the computer readable code by the processor to perform;

receiving text corresponding to the insurance claim by the receiving module, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups;

automatically separating the text into groups of words by the separating module;

identifying, by the text analyzer using a specialized insurance dictionary, insurance data elements of the insurance claim in the groups of words;

extracting, by the text analyzer, the insurance data elements related to the insurance claim'"'"'s subrogation potential;

storing, by the text analyzer, the extracted insurance data elements in data tables corresponding to the insurance claim;

developing a value for each of the insurance data elements by the assigning module, the value reflecting each insurance data element'"'"'s relevance to the claim subrogation potential, wherein the developing further comprises;

calculating the value using a set of rules created from existing historical claim data, or

assigning the value using the set of rules; and

evaluating the values developed for the insurance data elements by the

evaluating module to determine whether the insurance claim has subrogation potential.

6. The computer-implemented method of claim 5, wherein the value is a subrogation potential score.

7. The computer-implemented method of claim 5, wherein the values are based on historical data about subrogation of insurance claims.

8. The computer-implemented method of claim 5, wherein the values are based on industry practice regarding subrogation of insurance claims.

9. The computer-implemented method of claim 5, wherein the values are based on state law regarding subrogation of insurance claims.

10. A computer system for processing insurance claims comprising:

a processor; and

a memory storing computer readable code accessible by the processor for processing the insurance claims, the computer readable code comprising;

a text analyzer software component configured for;

identifying insurance data elements in text associated with an insurance claim using a specialized insurance dictionary,

extracting the insurance data elements related to the insurance claim'"'"'s subrogation potential, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups, and

storing, by the text analyzer software component, the extracted insurance data elements in data tables corresponding to the insurance claim; and

a rules engine software component configured for;

developing a subrogation potential score for each of the insurance data elements, wherein the developing further comprises;

calculating the subrogation potential score using a set of rules created from existing historical claim data, or

assigning the subrogation potential score using the set of rules; and

determining if the insurance claim has subrogation potential based on the subrogation potential scores developed for each of the insurance data elements.

11. The computer system of claim 10, wherein the text analyzer software component further comprises:

a word parser for separating the text into words;

a sentence splitter for collecting the words into groups; and

a grammatical parser for parsing the groups into the insurance data elements.

12. The computer system of claim 11, wherein the specialized insurance dictionary is used by at least one of the word parser, the sentence splitter, and the grammatical parser.

13. A computer system for processing an insurance claim, comprising:

a processor;

a memory storing computer readable code accessible by the processor for processing the insurance claims, the computer readable code comprising;

a text analyzer software component configured for;

receiving text corresponding to the insurance claim,

identifying insurance data elements in the text using a specialized insurance dictionary,

extracting the insurance data elements, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups, and

storing, by the text analyzer software component, the extracted insurance data elements in data tables corresponding to the insurance claim; and

a rules engine software component configured for;

developing a value for each of the data elements, the value reflecting each insurance data element'"'"'s relevance to claim subrogation potential, wherein the developing further comprises;

calculating the value using a set of rules created from existing historical claim data, or

assigning the value using the set of rules; and

evaluating the values developed for the insurance data elements to determine whether the insurance claim has subrogation potential.

14. The computer system of claim 13, further comprising a processor that runs the rules engine software component.

15. The computer system of claim 13, wherein the values are based on historical data about subrogation of insurance claims.

16. The computer system of claim 13, wherein the values are based on industry practice regarding subrogation of insurance claims.

17. The computer system of claim 13, wherein the values are based on state law regarding subrogation of insurance claims.

18. A computer usable medium having computer readable code embodied therein for processing insurance claims, the computer readable code comprising:

an analyzing module for;

identifying insurance data elements in text associated with an insurance claim using a specialized insurance dictionary,

extracting the insurance data elements related to the insurance claim'"'"'s subrogation potential, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups, and

storing the extracted insurance data elements in data tables corresponding to the insurance claim;

an assigning module for developing a subrogation potential score for each of the insurance data elements, wherein the developing further comprises;

calculating the subrogation potential score using a set of rules created from existing historical claim data, or

assigning the subrogation potential score using the set of rules; and

a determining module for determining if the insurance claim has subrogation potential based on the subrogation potential scores developed for each of the insurance data elements.

19. The computer usable medium of claim 18, wherein the analyzing module further comprises:

a separating module for separating the text into words;

a collecting module for collecting the words into groups; and

a parsing module for parsing the groups into the insurance data elements.

20. A computer usable medium having computer readable code embodied therein for processing an insurance claim, the computer readable code comprising:

a receiving module for receiving text corresponding to the insurance claim, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups;

a separating module for automatically separating the text into groups of words;

an analyzing module for;

identifying insurance data elements of an insurance claim the groups of words using a specialized insurance dictionary,

extracting the insurance data elements related to the insurance claim'"'"'s subrogation potential, and

storing the extracted insurance data elements in data tables corresponding to the insurance claim;

an assigning module for developing a value for each of the insurance data elements, the value reflecting each insurance data element'"'"'s relevance to claim subrogation potential, wherein the developing further comprises;

calculating the value using a set of rules created from existing historical claim data, or

assigning the value using the set of rules; and

an evaluating module for evaluating the values developed for the insurance data elements to determine whether the insurance claim has subrogation potential.

21. The computer usable medium of claim 20, wherein the value is a subrogation potential score.

22. A computer-implemented method for processing insurance claims in a computer system having a plurality of software components, the method comprising:

providing a processor and a memory storing computer readable code accessible by the processor for processing the insurance claims, the computer readable code comprising a text analyzer and a referral engine, and

executing the computer readable code by the processor to perform;

identifying, by the text analyzer using a specialized insurance dictionary, insurance data elements in text associated with an insurance claim;

extracting, by the text analyzer, the insurance data elements related to the insurance claim'"'"'s subrogation potential, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups;

storing, by the text analyzer, the extracted insurance data elements in data tables corresponding to the insurance claim; and

determining, as a function of subrogation potential scores associated with at least a set of the insurance data elements by the referral engine, wherein the subrogation potential scores are developed by

calculating the subrogation potential score using a set of rules created from existing historical claim data, or

assigning the subrogation potential score using the set of rules, whether the insurance claim is to be referred for subrogation.

23. The computer-implemented method of claim 22, further comprising:

developing the subrogation potential scores for the set of insurance data elements.

24. The computer-implemented method of claim 22, wherein the identifying further comprises:

separating the text into words;

collecting the words into groups; and

parsing the groups into the insurance data elements.

25. The computer-implemented method of claim 22, further comprising:

applying a rule that specifies the set of insurance data elements and the subrogation potential scores associated with the set of insurance data elements.

26. A computer system for processing insurance claims comprising:

a processor;

a memory storing computer readable code accessible by the processor for processing the insurance claims, the computer readable code comprising;

a text analyzer software component configured for;

identifying insurance data elements in text associated with an insurance claim using a specialized insurance dictionary,

extracting the insurance data elements related to the insurance claim'"'"'s subrogation potential, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups, and

storing, by the text analyzer software component, the extracted insurance data elements in data tables corresponding to the insurance claim; and

a referral engine software component configured for determining, as a function of subrogation potential scores associated with at least a set of the insurance data elements, wherein the subrogation potential scores are developed by

calculating the subrogation potential score using a set of rules created from existing historical claim data, or

assigning the subrogation potential score using the set of rules, whether the insurance claim is to be referred for subrogation.

27. The computer system of claim 26, wherein the referral engine further develops the subrogation potential scores for the set of insurance data elements.

28. The computer system of claim 26, wherein the text analyzer software component further separates the text into words, collects the words into groups, and parses the groups into the insurance data elements.

29. A computer usable medium having computer readable code embodied therein for processing insurance claims, the computer readable code comprising:

an analyzing module for;

identifying insurance data elements in text associated with an insurance claim using a specialized insurance dictionary,

extracting the insurance data elements related to the insurance claim'"'"'s subrogation potential, the text comprising at least one of the following;

sentence textual groups and non-sentence textual groups, and

storing the extracted insurance data elements in data tables corresponding to the insurance claim;

a determining module for determining, as a function of subrogation potential scores associated with at least a set of the insurance data elements, wherein the subrogation potential scores are developed by

calculating the subrogation potential score using a set of rules created from existing historical claim data, or

assigning the subrogation potential score using the set of rules, whether the insurance claim is to be referred for subrogation; and

a processing module to run the analyzing module and the determining module.

30. The computer usable medium of claim 29, further comprising:

an assigning module for developing the subrogation potential scores for the set of insurance data elements.

31. The computer usable medium of claim 29, wherein the analyzing module further comprises:

a separating module for separating the text into words;

a collecting module for collecting the words into groups; and

a parsing module for parsing the groups into the insurance data elements.

32. The computer usable medium of claim 29, further comprising:

an applying module for applying a rule that specifies the set of insurance data elements and the subrogation potential scores associated with the set of insurance data elements.