System and method using a predictive model for nurse intervention program decisions
First Claim
1. A computer system for facilitating provisioning of a nurse intervention program, comprising:
- a data storage module for receiving, storing, and providing access to data related to historical insurance claim information, including historical injury information and historical insurance claim result information, and to current insurance claim transactions, including current insurance claim transaction injury information;
a predictive model component, coupled to the data storage module, for determining whether to identify one of said current insurance claim transactions for referral to the nurse intervention program;
a computer processor for executing programmed instructions and for storing and retrieving said data related to current insurance claim transactions;
a program memory, coupled to the computer processor, for storing program instruction steps for execution by the computer processor;
a model training component, coupled to the computer processor, for (i) automatically training the predictive model component based on a first subset of the data related to the historical insurance claim information, including both historical injury information and historical insurance claim result information and (ii) automatically verifying the trained predictive model component based on a second subset of the data related to the historical insurance claim information, different than the first subset, in accordance with program instructions stored in the program memory and executed by the computer processor, thereby providing a trained and verified predictive model component;
an output device, coupled to the computer processor, for outputting an output indicative of whether said one of said current insurance claim transactions should be referred to the nurse intervention program, wherein the computer processor generates the output in accordance with program instructions in the program memory and executed by the computer processor, said output generated in response to a notice of injury received in connection with said one of said current insurance claim transaction and being based on an application of data for said one of said current insurance claim transactions to the trained and verified predictive model component; and
a routing module for directing workflow based on the output from the output device.
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Accused Products
Abstract
According to some embodiments, historical claim data may be stored in a computer storage unit. The historical claim data may be used to train and verify a predictive model, the predictive model being associated with an evaluation of claim transactions to determine whether to refer each claim transactions to a nurse intervention program. Data for current claim transactions may be processed, and the trained and verified predictive model may be applied to the data for the current claim transactions to generate a respective output for each of the current claim transactions. Some of the current claim transactions may be selectively routed to a case management center associated with the nurse intervention program based on the outputs generated by the predictive model.
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Citations
14 Claims
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1. A computer system for facilitating provisioning of a nurse intervention program, comprising:
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a data storage module for receiving, storing, and providing access to data related to historical insurance claim information, including historical injury information and historical insurance claim result information, and to current insurance claim transactions, including current insurance claim transaction injury information; a predictive model component, coupled to the data storage module, for determining whether to identify one of said current insurance claim transactions for referral to the nurse intervention program; a computer processor for executing programmed instructions and for storing and retrieving said data related to current insurance claim transactions; a program memory, coupled to the computer processor, for storing program instruction steps for execution by the computer processor; a model training component, coupled to the computer processor, for (i) automatically training the predictive model component based on a first subset of the data related to the historical insurance claim information, including both historical injury information and historical insurance claim result information and (ii) automatically verifying the trained predictive model component based on a second subset of the data related to the historical insurance claim information, different than the first subset, in accordance with program instructions stored in the program memory and executed by the computer processor, thereby providing a trained and verified predictive model component; an output device, coupled to the computer processor, for outputting an output indicative of whether said one of said current insurance claim transactions should be referred to the nurse intervention program, wherein the computer processor generates the output in accordance with program instructions in the program memory and executed by the computer processor, said output generated in response to a notice of injury received in connection with said one of said current insurance claim transaction and being based on an application of data for said one of said current insurance claim transactions to the trained and verified predictive model component; and a routing module for directing workflow based on the output from the output device. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13)
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14. A computer-implemented method of managing nurse intervention program decisions, the method comprising:
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storing, in a computer storage unit, historical claim data, including historical injury information and historical insurance claim result information; using a first subset of the historical claim data, by a computer processor, to develop a predictive model having a plurality of historical claim data inputs and variables, developing the predictive model including; performing data cleansing to eliminate one or more data inputs in the predictive model; performing data reduction to reduce the number of variables in the predictive model; and performing data transformations to normalize variables in the predictive model, the predictive model for evaluating claim transactions to determine whether to refer the claim transactions to a nurse intervention program; using a second subset of the historical claim data, different than the first subset, to verify the developed predictive model; automatically applying, by the computer processor, the verified predictive model to the data for the current claim transactions to generate a respective output for each of the current claim transactions, said generation being automatically performed for a current insurance claim both after a first time period and a second time period, the second time period being different than the first time period; and selectively routing, by the computer processor, ones of the current claim transactions to a case management center associated with the nurse intervention program based on the outputs generated by the predictive model.
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Specification