Determining amounts for claims settlement using likelihood values

• US 8,219,424 B2
• Filed: 06/06/2008
• Issued: 07/10/2012
• Est. Priority Date: 01/18/2008
• Status: Expired due to Fees

• Current Assignee: Computer Sciences Corporation (DXC Technology Company)
• Original Assignee: Computer Sciences Corporation (DXC Technology Company)
• Inventors: Scalet, Frank, Henry, Scott, Watters, Clifton, Dulock, Scott
• Primary Examiner(s): Kyle, Charles
• Assistant Examiner(s): NIQUETTE, ROBERT R
• Application Number:
  US12/134,991
• Publication Number:
  US 20090187429A1
• Time in Patent Office: 1,495 Days
• Field of Search: None
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 50/188 Electronic negotiation

Abstract

Methods and systems are provided for determining and displaying amounts for use in settling insurance claims are disclosed. Closed claims that match an open claim are identified based on one or more characteristics of the open claim. A likelihood value associated with at least one of the matching closed claims is determined. An amount for use by an adjuster in settling the open claim is determined based on the likelihood value for at least one of the matching claims. A most likely amount and most likely range associated with the open claim may be determined based on the likelihood values.

Claims

1. A computer-implemented method for determining amounts for use in settling insurance claims, comprising:

automatically identifying on an insurance claims processing system one or more closed claims that match an open claim based on one or more characteristics of the open claim;

automatically determining on the insurance claims processing system a likelihood value associated with at least one of the matching closed claims, wherein the likelihood value is a numerical value whose magnitude is a quantitative measure of the likelihood that a monetary amount associated with the closed claim represents an appropriate monetary amount for settling an open claim, wherein a greater magnitude of the likelihood value corresponds to a higher likelihood that the monetary amount associated with the closed claim represents an appropriate monetary amount for settling the open claim, and wherein a lesser magnitude of the likelihood value corresponds to a lower likelihood that the monetary amount associated with the closed claim represents an appropriate monetary amount for settling the open claim; and

determining an amount for the open claim based at least in part on the likelihood value for at least one of the matching closed claims.

2. The method of claim 1, wherein determining the likelihood value of at least one of the matching claims comprises maximum likelihood estimation.

3. The method of claim 1, wherein the amount for the open claim is a most likely amount, wherein the most likely amount is an amount mathematically most likely to represent a good value for settlement of a claim.

4. The method of claim 3, wherein the most likely amount is an amount mathematically most likely to represent a good value for settlement of a claim, wherein the most likely amount corresponds to the matching closed claim with the highest likelihood value of the likelihood values associated with the matching closed claims.

5. The method of claim 1, wherein the amount is a general damages amount.

6. The method of claim 1, wherein the amount is a medicals amount.

7. The method of claim 1, further comprising determining a most likely range associated with the open claim based at least in part on the likelihood value associated with at least one of the matching closed claims, wherein the most likely range is a range mathematically most likely to represent a good range for settlement of a claim.

8. The method of claim 1, further comprising determining which of the matching closed claims fall into a predetermined range within a likelihood curve for the matching closed claims, wherein the likelihood curve represents likelihood values of one or more closed claims as a function of monetary amount.

9. The method of claim 8, wherein the predetermined range is the top quartile of the likelihood curve for the matching closed claims.

10. The method of claim 1, wherein the most likely settlement amount includes at least one adjustment for disfigurement, medical expenses, lost wages, comparative negligence, or contribution, wherein the most likely settlement amount is an amount mathematically most likely to represent a good value for settlement of a claim.

11. The method of claim 1, wherein determining a likelihood value associated with a least one of the matching closed claims comprises determining likelihood values associated with at least two matching closed claims, wherein the determined amount for the open claim is based at least in part on the highest likelihood value of the determined likelihood values.

12. The method of claim 1, further comprising adjusting an amount for at least one of the matching closed claims based on at least one characteristic of the matching closed claim.

13. The method of claim 12, wherein the amount for the open claim is based at least in part on a most likely amount, wherein the most likely amount is an amount mathematically most likely to represent a good value for settlement of a claim.

14. The method of claim 1, wherein determining a likelihood value associated with a least one of the matching closed claims comprises calculating a kernel density estimate associated with the matching closed claim, and using the kernel density estimate to determine the likelihood value for the matching closed claim.

15. The method of claim 14, wherein calculating a kernel density estimate associated with the matching closed claim comprises determining a bandwidth for the kernel density estimate associated with the matching closed claim.

16. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises determining whether a major injury for the open claim is predominantly a demonstrable injury or not a demonstrable injury.

17. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises determining a most injured body part for the open claim.

18. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises determining one or more medical codes for at least one injury to a claimant for the open claim.

19. The method of claim 18, wherein determining an amount for the open claim comprises determining a combined value for at least one body part if more than one medical code is determined for the injury.

20. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises identifying a dominant medical feature associated with at least one injury to a claimant for the open claim.

21. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises ranking or rating at least one of the matching claims.

22. The method of claim 1, wherein identifying the one or more closed claims that match an open claim comprises applying at least one filter to a set of closed claim data, wherein the filter is configured to decrease or increase the number of closed claims that are identified to match the open claim from the set of closed claims data.

23. The method of claim 22, wherein at least one of the applied filters considers whether EDR data indicates that an injury associated with the claim was low-impact.

24. The method of claim 22, further comprising selecting at least one filter setting, wherein the filter settings include at least two filter settings, wherein at least one of the setting is looser than at least one other of the settings, wherein the looser of the filter settings is configured to identify more claims than the at least one other setting.

25. The method of claim 22, further comprising:

changing at least one filter setting to be tighter or looser after the matching closed claims are identified; and

identifying an updated set of matching closed claims based on the tightened or loosened filter setting.

26. The method of claim 1, further comprising displaying at least one likelihood value associated with at least one of the matching closed claims.

27. A system, comprising:

a processor;

a memory coupled to the processor and configured to store program instructions executable by the processor to implement;

identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim;

determining a likelihood value associated with at least one of the matching closed claims, wherein the likelihood value is a numerical value whose magnitude is a quantitative measure of the likelihood that a monetary amount associated with the closed claim represents an appropriate monetary amount for settling an open claim, wherein a greater magnitude of the likelihood value corresponds to a higher likelihood that the monetary amount associated with the closed claim represents an appropriate monetary amount for settling the open claim, and wherein a lesser magnitude of the likelihood value corresponds to a lower likelihood that the monetary amount associated with the closed claim represents an appropriate monetary amount for settling the open claim; and

determining an amount for the open claim based at least in part on the likelihood value for at least one of the matching closed claims.

28. A tangible, computer readable medium comprising program instructions, wherein the program instructions are computer-executable to implement:

identifying one or more closed claims that match an open claim based on one or more characteristics of the open claim;

determining a likelihood value associated with at least one of the matching closed claims, wherein the likelihood value is a numerical value whose magnitude is a quantitative measure of the likelihood that a monetary amount associated with the closed claim represents an appropriate monetary amount for settling an open claim, wherein a greater magnitude of the likelihood value corresponds to a higher likelihood that the monetary amount associated with the closed claim represents an appropriate monetary amount for settling the open claim, and wherein a lesser magnitude of the likelihood value corresponds to a lower likelihood that the monetary amount associated with the closed claim represents an appropriate monetary amount for settling the open claim; and

determining an amount for the open claim based at least in part on the likelihood value for at least one of the matching closed claims.