System and method for managing account processing

• US 7,957,986 B1
• Filed: 04/09/2002
• Issued: 06/07/2011
• Est. Priority Date: 04/09/2001
• Status: Active Grant

• Current Assignee: Equian, LLC (UnitedHealth Group Incorporated)
• Original Assignee: Trover Solutions, Inc. (UnitedHealth Group Incorporated)
• Inventors: Bates, Mark, Altieri, Nickolas V., Tokuuke, Bobby T., Taylor, Tom, Hail, Mitzi R., Hayes, Berry Sr.
• Primary Examiner(s): Koppikar; Vivek D
• Application Number:
  US10/118,060
• Time in Patent Office: 3,346 Days
• Field of Search: 705 2- 4
• 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 managing subrogation and recovery of insurance claims with a computer including receiving data for a first insurance claim; determining from the data whether the first insurance claim has recovery potential; thereafter when it is determined that the first insurance claim has recovery potential, collecting information about the event from which the first insurance claim was derived; repeatedly seeking data, as necessary, for additional insurance claims associated with the event such that all insurance claims arising from the event are processed together.

Claims

1. A system for managing insurance claims with a computer comprising:

a processor; and

a memory containing program instructions which, when executed by the processor, cause the system to perform a method, the method comprising;

receiving data for a first insurance claim by an injured party;

determining from the data whether the first insurance claim has recovery potential;

thereafter when it is determined that the first insurance claim has recovery potential, collecting information about an event from which the first insurance claim was derived;

creating a request for information regarding additional insurance claims related to the first insurance claim which were paid within a specified time period surrounding the date of the event from which the first insurance claim was derived;

receiving a history file comprising data for claims for the injured party from the specified time period;

comparing the data for the first insurance claim with the data contained in the history file to detect whether additional insurance claims arose from the event; and

when the additional insurance claims are detected, processing the first insurance claim and the additional insurance claims together.

2. The system for managing insurance claims with a computer of claim 1, wherein determining from the data whether the first insurance claim has recovery potential comprises:

applying weights to specified portions of the data;

adding the weighted values together;

comparing the sum of the weighted values to a threshold value.

3. The system for managing insurance claims with a computer of claim 2, wherein the specified portions are selected from a diagnosis code, a length of time between an injury and a treatment, and an age of the injured person when the injury occurred.

4. The system for managing insurance claims with a computer of claim 1, wherein collecting information about the event from which the first insurance claim was derived comprises:

determining information required to process the claim, based on predefined criteria reflected by the first insurance claim including at least one of an injury type, age of the injured person, date of injury, date of treatment, length of time from injury to treatment, recovery source, jurisdiction in which the injury occurred, client, value of the first insurance claim, and type of treatment;

generating and sending a request for the required information to an insurance subscriber;

receiving information from the insurance subscriber;

determining whether all required information has been received;

generating additional requests for information, provided all required information has not been received.

5. The system for managing insurance claims with a computer of claim 4, wherein the method further comprises determining whether to reject a claim based, at least in part on, the information received from the insurance subscriber and predefined legal provisions.

6. The system for managing insurance claims with a computer of claim 1, wherein the method further comprises assigning one or more related insurance claims to a recovery specialist based on expertise of the recovery specialist and predefined criteria reflected by the first insurance claim, including at least one of an injury type, age of the injured person, date of injury, date of treatment, length of time from injury to treatment, recovery source, jurisdiction in which the injury occurred, client, value of the first insurance claim, and type of treatment.

7. The system for managing insurance claims with a computer of claim 1, wherein the method further comprises recording information about all actions taken during the processing of the first insurance claim.

8. The system for managing insurance claims with a computer of claim 1, further comprising determining whether the data for the additional insurance claims duplicates data for the first insurance claim or data for other insurance claims associated with the first insurance claim.

9. The system for managing insurance claims with a computer of claim 1, wherein the method further comprises:

creating a list of tasks for processing the first insurance claim in consideration of predefined criteria reflected by the first insurance claim, the predefined criteria including at least one of;

an injury type, age of the injured person, date of injury, date of treatment, length of time from injury to treatment, recovery source, jurisdiction in which the injury occurred, client, value of the first insurance claim, and type of treatment.

10. The system for managing insurance claims with a computer of claim 1, wherein the method further comprises creating a projection of the amount of recovery for the first insurance claim in consideration of applicable laws and specified criteria reflected by the first insurance claim, including at least one of an injury type, age of the injured person, date of injury, date of treatment, length of time from injury to treatment, recovery source, jurisdiction in which the injury occurred, client, value of the first insurance claim, and type of treatment.

11. The system for managing insurance claims with a computer of claim 10, wherein the method further comprises generating a probability that the projected recovery will be received by a specified date.

12. The system for managing insurance claims with a computer of claim 1, wherein the method further comprises generating statistics for use in analyzing efficiency in managing subrogation and recovery of insurance claims.

13. A system for managing insurance claims with a computer comprising:

a server which;

receives data for a first insurance claim by an injured party;

determines from the data whether the first insurance claim has recovery potential, wherein the server is adapted to;

collect information about an event from which the first insurance claim was derived after it is determined that the first insurance claim has recovery potential;

create a request for information regarding additional insurance claims related to the first insurance claim which were paid within a specified time period surrounding the date of the event from which the first insurance claim was derived;

receive a history file comprising data for claims for the injured party from the specified time period;

compare the data for the first insurance claim with the data contained in the history file to detect whether additional insurance claims arose from the event; and

when the additional insurance claims are detected, process the first insurance claim and the additional insurance claims together;

one or more terminals connected to the server for recovery specialists to utilize in managing subrogation and recovery of insurance claims; and

at least one client computer associated with an insurance company connected to the server for transferring data associated with insurance claims to the server.