Automation of auditing claims

• US 8,447,638 B2
• Filed: 09/12/2012
• Issued: 05/21/2013
• Est. Priority Date: 05/29/2009
• Status: Active Grant

• Current Assignee: HyperQuest, Inc. (Solera Holdings Incorporated)
• Original Assignee: HyperQuest, Inc. (Solera Holdings Incorporated)
• Inventors: Hogan, Dennis M., Hogan, Jeffrey J.
• Primary Examiner(s): Tran, Hai
• Application Number:
  US13/610,972
• Publication Number:
  US 20130006614A1
• Time in Patent Office: 251 Days
• Field of Search: 705/4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/102 Bill distribution or payments
• CPC Class Codes: G06Q 30/0222 During e-commerce, i.e. online transactions
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

Described are computer-based methods and apparatuses, including computer program products, for automation of auditing claims. A data file is received comprising one or more auditable items, each auditable item comprising a word string having one or more words. Each word string for each auditable item is translated using one or more translation steps into a translated item description. Each translated item description is compared to a plurality of terms to generate matching information. Each translated item description is associated with an item identifier based on the matching information. Each auditable item is accepted or rejected based on the item identifier and one or more rules associated with the data file.

Claims

1. A computerized auditing method comprising:

receiving, via a processor, a data file comprising one or more auditable items, each auditable item being a line item from an insurance claim file, where each auditable item comprises a word string having one or more words;

translating, using the processor, each word string for each auditable item using one or more translation steps into a translated item description;

comparing, using the processor, each translated item description to a plurality of terms to generate matching information;

associating, using the processor, each translated item description with an item identifier based on the matching information; and

using the processor, accepting or rejecting each auditable item based on the item identifier and one or more rules associated with the data file.

2. The method of claim 1 further comprising:

determining the item identifier is rejected for an auditable item; and

rejecting the auditable item;

or

determining the item identifier is accepted for the auditable item; and

accepting the auditable item.

3. The method of claim 1 further comprising:

unsuccessfully translating a word string into a translated item description; and

logging the word string as an unsuccessful translation.

4. The method of claim 1, wherein translating comprises preprocessing the word string.

5. The method of claim 4, wherein preprocessing comprises removing one or more orientation words from the word string, removing one or more unnecessary words from the word string, adding a space before one or more punctuation marks in the word string, or any combination thereof.

6. The method of claim 1, wherein translating the word string comprises:

determining the word string comprises header information; and

processing the word string based on the header information.

7. The method of claim 1, wherein translating the word string comprises:

determining the word string comprises one or more ambiguous words from a plurality of ambiguous words; and

processing the word string based on the one or more ambiguous words.

8. The method of claim 1, wherein:

the data file comprises an automobile insurance demand file; and

the one or more word strings comprise one or more repair part descriptions.

9. The method of claim 8, wherein:

the data file further comprises one or more recommended part descriptions for repair of the vehicle; and

the one or more rules associated with the data file are based on the one or more recommended part descriptions for repair.

10. A computerized auditing method comprising:

translating, using a processor, a word string of an auditable item using one or more translation steps into a translated item description, wherein the one or more translation steps include determining the word string comprises one or more standard words from a plurality of standard words and removing the one or more standard words from the word string, and wherein the auditable item is a line item from an insurance claim file; and

using the processor, accepting or rejecting the auditable item based on the translating.

11. A computerized auditing method comprising:

translating, using a processor, a word string of an auditable item using one or more translation steps into a translated item description, wherein the one or more translation steps include determining the word string comprises one or more specific words from a plurality of specific words and removing the one or more specific words from the word string, and wherein the auditable item is a line item from an insurance claim file; and

using the processor, accepting or rejecting the auditable item based on the translating.

12. The method of claim 11, wherein the plurality of specific words comprise predetermined word strings, structural part groupings, abbreviations, metric indicators, computer generated formats, non-alphanumeric characters, single letters, or any combination thereof.

13. The method of claim 12, wherein the metric indicators are alphanumeric, alpha, and numerical characters dealing with metrics.

14. A computerized auditing method comprising:

translating, using a processor, a word string of an auditable item using one or more translation steps into a translated item description, wherein the one or more translation steps include determining the word string comprises one or more abbreviations from a plurality of abbreviations and for each of the one or more abbreviations processing the word string based on the abbreviations, and wherein the auditable item is a line item from an insurance claim file; and

using the processor, accepting or rejecting the auditable item based on the translating.

15. A computerized auditing method comprising:

translating, using a processor, a word string of an auditable item using one or more translation steps into a translated item description, wherein the auditable item is a line item from an insurance claim file; and

using the processor, accepting or rejecting the auditable item based on the translating, wherein translating the word string comprises;

applying one or more rules from a plurality of rules to the word string, wherein each rule is associated with a logic for processing the word string;

determining whether the word string contains one or more predetermined items; and

if the word string contains one or more predetermined items, for each predetermined item, processing the word string based on the predetermined item.

16. The method of claim 15 further comprising, for each predetermined item:

determining whether the word string satisfies a condition associated with the predetermined item; and

if the word string satisfies the condition, generating the translated item description.

17. The method of claim 16 further comprising:

determining whether the translated item description was not generated; and

if the translated item description was not generated, generating the translated item description based on a statistical estimation.

18. The method of claim 15, wherein the one or more rules comprises one or more specific item rules, one or more combination rules, or any combination thereof.

19. The method of claim 15, wherein the one or more predetermined items comprises one or more terms, one or more punctuation marks, or any combination thereof.

20. The method of claim 15, further comprising:

determining the word string comprises one word; and

generating the translated item description to include the one word.

21. A computerized auditing method comprising:

translating, using a processor, a word string of an auditable item using one or more translation steps into a translated item description, wherein the auditable item is a line item from an insurance claim file; and

using the processor, accepting or rejecting the auditable item based on the translating, wherein translating the word string comprises;

applying one or more combination rules to the word string, wherein each rule is associated with a logic for processing the word string;

comparing the word string against a build table to generate a relationship between words of the word string, the build table comprising one or more index words, each index word being associated with index information; and

generating the translated item description based on the relationship.

22. The method of claim 21, further comprising:

determining whether the word string comprises one or more predetermined items; and

for each predetermined item of the word string, processing the word string based on the predetermined item.

23. The method of claim 21, wherein the index information comprises noun information, adjective information, orientation information, or any combination thereof.

24. The method of claim 21, wherein comparing comprises, for each word in the word string:

determining whether the word is an orientation word;

if the word is an orientation word, modifying the word string based on the orientation word;

if the word is not an orientation word;

determining whether one or more remaining words in the word string match a list of preceding terms;

for each word that matches the list of preceding terms, recording a preceding relationship;

determining whether one or more remaining words in the word string match a list of anteceding terms; and

for each word that matches the list of anteceding terms, recording an anteceding relationship.

25. The method of claim 21, further comprising:

determining at least one word of the word string is not associated with a relationship; and

processing one or more non-orientation words of the word string.

26. The method of claim 25, wherein processing the one or more non-orientation words comprises:

for each non-orientation word of the word string;

determining whether the non-orientation word is associated with a build number;

if the non-orientation word is not associated with a build number, associating the non-orientation word with a generic build number;

arranging the word string based on the relationship;

determining whether the word string satisfies a proper relationship criteria; and

if the word string does not satisfy the proper relationship criteria, logging the word string.

27. The method of claim 21, wherein the one or more predetermined items comprise one or more punctuation marks, one or more joinable words, or any combination thereof.