Systems and methods for managing insurance claims

• US 7,840,422 B1
• Filed: 08/06/2003
• Issued: 11/23/2010
• Est. Priority Date: 04/09/2002
• Status: Active Grant

• Current Assignee: Equian, LLC (UnitedHealth Group Incorporated)
• Original Assignee: Trover Solutions, Inc. (UnitedHealth Group Incorporated)
• Inventors: Tokuuke, Bobby T., Moore, William C., Taylor, Thomas E., Hayes, Berry L. Sr., Hail, Mitzi R.
• Primary Examiner(s): Koppikar; Vivek D
• Application Number:
  US10/634,893
• Time in Patent Office: 2,666 Days
• Field of Search: 705 2- 4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Methods and systems for managing insurance claims include facilitating prepayment decisions, provider bill auditing, and recovery of paid claims. Prepayment decisions include, for example, determining whether to pay, deny, or defer an insurance claim submitted by an insured. Provider bill auditing may include, for example, examining bills related to an insurance claim for accuracy. Recovery of paid claims may include managing litigations and calculating fees due for recovery services.

Claims

1. A computer-implemented method for managing insurance claims, comprising the steps, performed by a computer, of:

receiving data related to an insurance claim via a network;

determining whether the insurance claim has recovery potential by using the received data to compare a value of the insurance claim with a threshold amount, wherein the insurance claim is determined to have a recovery potential when the value is greater than the threshold amount;

if it is determined that the insurance claim has recovery potential,

providing a characteristic of the insurance claim, and

automatically evaluating the characteristic of the insurance claim;

searching a client database to determine if other claims exist for an insured individual associated with the claim;

delaying payment pending investigation based on a determination that no other claim exists for the insured individual; and

establishing a payment decision for the insurance claim based on at least one of the received data and the evaluation of the characteristic.

2. The method of claim 1, wherein the data related to the insurance claim includes at least one of a treatment code, a provider, and a claim value.

3. The method of claim 1, wherein the providing step further includes:

determining whether a related insurance claim has been received.

4. The method of claim 1, wherein the providing step further includes:

determining whether a worker'"'"'s compensation claim corresponding to the insurance claim has been accepted.

5. The method of claim 1, wherein the providing step further includes:

determining whether first party insurance coverage corresponding to the insurance claim is available.

6. The method of claim 1, wherein the determining step further includes:

applying weights to specified portions of the data related to the insurance claim to obtain weighted values;

adding the weighted values to obtain a result;

comparing the result to a likely recovery value; and

determining that the insurance claim has recovery potential when the result is above the likely recovery value.

7. A system for managing insurance claims, comprising:

a receiving component configured to receive data related to an insurance claim via a network;

a determining component configured to determine whether the insurance claim has recovery potential by using the received data to compare a value of the insurance claim with a threshold amount, wherein the insurance claim is determined to have a recovery potential when the value is greater than the threshold amount;

a providing component configured to provide a characteristic of the insurance claim and to automatically evaluate the characteristic, if the determining component determines that the insurance claim has recovery potential;

a searching component for searching a client database to determine if other claims exist for an insured individual associated with the claim;

an investigation component for delaying payment pending investigation based on a determination that no other claim exists for the insured individual; and

an establishing component configured to establish a payment decision for the insurance claim based on at least one of the received data and the evaluation of the characteristic.

8. The system of claim 7, wherein the data related to the insurance claim includes at least one of a treatment code, a provider, and a claim value.

9. The system of claim 7, wherein the providing component further includes:

a determining component configured to determine whether a related insurance claim has been received.

10. The system of claim 7, wherein the providing component further includes:

a determining component configured to determine whether a worker'"'"'s compensation claim corresponding to the insurance claim has been accepted.

11. The system of claim 7, wherein the providing component further includes:

a determining component configured to determine whether first party insurance coverage corresponding to the insurance claim is available.

12. The system of claim 7, wherein the determining component further includes:

an applying component configured to apply weights to specified portions of the data related to the insurance claim to obtain weighted values;

an adding component configured to add the weighted values to obtain a result;

a comparing component configured to compare the result to a likely recovery value; and

a determining component configured to determine that the insurance claim has recovery potential when the result is above the likely recovery value.

13. A system for managing insurance claims, comprising:

means for receiving data related to an insurance claim via a network;

means for determining whether the insurance claim has recovery potential by using the received data to compare a value of the insurance claim with a threshold amount, wherein the insurance claim is determined to have a recovery potential when the value is greater than the threshold amount;

means for providing a characteristic of the insurance claim, and automatically evaluating the characteristic of the insurance claim, if it is determined that the insurance claim has recovery potential;

means for searching a client database to determine if other claims exist for an insured individual associated with the claim;

means for delaying payment pending investigation based on a determination that no other claim exists for the insured individual; and

means for establishing a payment decision for the insurance claim based on at least one of the received data and the evaluation of the characteristic.

14. A computer-usable storage medium having computer-readable code embodied therein for managing insurance claims, the computer-readable code comprising:

a receiving module configured to receive data related to an insurance claim via a network;

a determining module configured to determine whether the insurance claim has recovery potential by using the received data to compare a value of the insurance claim with a threshold amount, wherein the

insurance claim is determined to have a recovery potential when the value is greater than the threshold amount;

a providing module configured to provide a characteristic of the insurance claim and automatically evaluate the characteristic of the insurance claim, if it is determined that the insurance claim has recovery potential;

a searching module for searching a client database to determine if other claims exist for an insured individual associated with the claim;

an investigation module for delaying payment pending investigation based on a determination that no other claim exists for the insured individual; and

an establishing module configured to establish a payment decision for the insurance claim based on at least one of the received data and the evaluation of the characteristic.