System and method for identification, perfection, collection, and valuation of third-party claims including subrogation claims

• US 8,615,409 B1
• Filed: 11/19/2009
• Issued: 12/24/2013
• Est. Priority Date: 04/15/2005
• Status: Expired due to Fees

• Current Assignee: Recovery Data Connect LLC (Vivius Holdings LLC)
• Original Assignee: Recovery Data Connect LLC (Vivius Holdings LLC)
• Inventors: McKown, James R.
• Primary Examiner(s): NGUYEN, HIEP VAN
• Application Number:
  US12/622,247
• Time in Patent Office: 1,496 Days
• Field of Search: 705/20, 705/2
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/14 specially adapted for billing systems
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G06Q 50/18 Legal services

Abstract

A method has been provided that associates insurance payment linking information with litigation information and associates insurance payment information with the insurance payment linking information and the litigation information to identify a potential third-party claim or a potential subrogation claim. Associating the insurance payment linking information with the litigation information may further include associating at least one medical procedure code with at least some of the litigation information.

Claims

1. A method of identifying a potential third-party claim or a potential subrogation claim, the method comprising:

receiving, in a computer system, insurance payment information, the insurance payment information comprising information concerning patients, members or insureds;

receiving, in the computer system, litigation information, the litigation information comprising information concerning parties in lawsuits;

analyzing, in the computer system, the commonality of data elements in the insurance payment information that identify one or more patients, members or insureds with data elements in the litigation information that identify one or more of the parties in lawsuits;

matching, based on the common data elements, at least one of the patients, members or insureds in the insurance payment information with at least one of the parties in the lawsuits;

identifying a potential third-party claim or a potential subrogation claim against one of the parties in lawsuits based on the matching; and

wherein the insurance payment information is not directly or indirectly matched with the litigation information for a potential third-party claim or a potential subrogation claim prior to the analyzing and matching.

2. The method of claim 1, wherein the matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits comprises matching at least two of the following data elements:

a first name or initial, a last name or initial, a middle name or initial, a home address, a mailing address, a city, a county, a metropolitan area, a state, a zip code initial three digits, a date of birth, a year of birth, or age.

3. The method of claim 1, wherein the matching the at least one of the patients, members or insured in the insurance payment information with the at least one of the parties in the lawsuits comprises matching at least the following data elements:

geographic information associated with the insurance payment information with geographic information associated with a court in which a lawsuit was filed.

4. The method of claim 1, wherein the matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits comprises matching at least the following data elements:

medical providers disclosed in the insurance payment information with one or more defendants in the lawsuits.

5. The method of claim 1, wherein the matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits comprises matching at least three of the following data elements:

a first name or initial, a last name or initial, a middle name or initial, a home address, a mailing address, a city, a county, a metropolitan area, a state, a zip code initial three digits, a date of birth, a year of birth, or age.

6. The method of claim 1, wherein

the litigation information comprises claims corresponding to the parties the lawsuits;

the insurance payment information comprises information concerning payments made to or on behalf of the patients, members or insureds; and

the matching further comprises matching the claims corresponding to the at least one of the parties in the lawsuit with the payments made to the at least one of the patients, members or insureds in the insurance payment information.

7. The method of claim 6, further comprising:

analyzing the matching to determine a confidence level associated with the match, the confidence level representing both a confidence that the at least one of the patients, members or insureds in the insurance payment information and the at least one of the parties in the lawsuits are the same person and a confidence that the claims corresponding to the at least one of the parties in the lawsuit is linked with the payments made to the at least one of the patients, members or insureds in the insurance payment information; and

assigning, based on the analyzing the matching, a confidence level to the match.

8. The method of claim 1, further comprising:

receiving, in the computer system, identification information, the identification information received separate from the insurance payment information and the litigation information, the identification information operable to increase a level of confidence that the least one of the patients, members or insureds in the insurance payment information is the same person as the at least one of the parties in the lawsuits; and

linking the identification information to one of the at least one of the patients, members or insureds in the insurance payment information or the at least one of the parties in the lawsuits.

9. The method of claim 1, wherein the litigation information comprises claims corresponding to the parties in the lawsuits and the insurance payment information comprises information concerning payments made to or on behalf of the patients, members or insureds, the method further comprising:

analyzing the claims in the lawsuits to determine a type of suit or claim involved; and

assigning, based on the analysis of the claims in the lawsuits, insurance payment linking information to the claims, the insurance payment linking information operable to map or link claims in the litigation information to the information concerning payments made to or on behalf of the patients, members or insureds.

10. The method of claim 9, wherein the insurance payment linking information is medical procedure codes determined to be applicable to the type of suit or claim involved in the lawsuits and determined to be applicable to subrogation claims or third party claims.

11. The method of claim 10, wherein the medical procedure codes is one of a diagnostic related grouping (DRG) code category, an international classification of disease (ICD) code category, or a current procedural terminology (CPT) code category.

12. The method of claim 10, wherein

the information concerning payments made to or on behalf of the patients, members or insureds includes medical procedure codes;

and

the matching further comprises matching medical procedure codes for one or payments made to or on behalf of one or more patients, members or insureds with medical procedure codes assigned to one or more claims corresponding to one or more parties.

13. The method of claim 9, wherein

the analyzing the claims in the litigation information to determine a type of suit or claim involved comprises analyzing one or more of keywords in the lawsuits, a nature of suit for the lawsuit, witnesses, third parties, or defendants in the lawsuit.

14. The method of claim 13, wherein

the assigning insurance payment linking information to the claims comprises for a combination of keywords in the lawsuits, a nature of suit of the lawsuit, witnesses, third parties, or defendants in the lawsuit, assigning insurance payment linking information determined to be applicable to the combination.

15. The method of claim 1, further comprising:

analyzing valuation information based on previous processing, resolution, or recovery of third party claims or subrogation claims; and

based on the analysis of the valuation information, assigning a value to the potential third-party claim or a potential subrogation.

16. The method of claim 1, further comprising:

analyzing at least one of total paid claims expended for a particular patient, member or insured;

total paid claims incurred during a time period deemed relevant based on an applicable statute of limitation for a corresponding lawsuit;

or paid claims related to a particular medical procedure code determined to be relevant to a type of lawsuit; and

based on the analysis of the valuation information, assigning a value to the potential third-party claim or a potential subrogation.

17. The method of claim 1, further comprising:

analyzing the matching to determine a confidence level associated with the match; and

based on the analyzing the matching, assigning a confidence level to the match to predict the likelihood that the least one of the patients, members or insureds in the insurance payment information and the at least one of the parties in the lawsuits are the same.

18. The method of claim 1, wherein the matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits comprises analyzing a service date for the patients, members, or insured to determine that a date a filing of the lawsuit comes after the respective service date for the patients, members or insureds.

19. The method of claim 1, wherein the matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits comprises analyzing a date of death of the patients, members, or insured to determine that a date a filing of the lawsuit comes after the respective date of death for the patients, members or insureds.

20. The method of claim 1, wherein after matching at least one of the patients, members or insureds in the insurance payment information with at least one of the parties in the lawsuits,

matching at least a second patient, member or insured in the insurance payment information with at least a second one of the parties in the lawsuits, the at least a second patient, member or insured in the insurance payment information being a second member on the same insurance policy as the at least one of the patients, members or insureds and the at least a second one of the parties in the lawsuits being a co-plaintiff with the at least one of the parties in the lawsuits.

21. A system for identifying a potential third-party claim or a potential subrogation claim, the system comprising:

logic stored in a computer readable media such that when executed by a processor;

receives insurance payment information, the insurance payment information comprising information concerning patients, members or insureds;

receives litigation information, the litigation information comprising information concerning parties in lawsuits;

analyzes the commonality of data elements in the insurance payment information that identify one or more patients, members or insureds with data elements in the litigation information that identify one or more of the parties in lawsuits;

matches, based on the common data elements, at least one of the patients, members or insureds in the insurance payment information with at least one of the parties in the lawsuits;

identifies a potential third-party claim or a potential subrogation claim against one of the parties in lawsuits based on the matching; and

wherein the insurance payment information is not directly or indirectly matched with the litigation information for a potential third-party claim or a potential subrogation claim prior to the analyzing and matching.

22. The system of claim 21, wherein the logic in matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits matches at least two of the following data elements:

a first name or initial, a last name or initial, a middle name or initial, a home address, a mailing address, a city, a county, a metropolitan area, a state, a zip code initial three digits, a date of birth, a year of birth, or age.

23. The system of claim 21, wherein the logic in matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits matches at least the following data elements:

geographic information associated with the insurance payment information with geographic information associated with a court in which a lawsuit was filed.

24. The system of claim 21, wherein the logic in matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits matches at least the following data elements:

providers of the insurance payment information with one or more defendants in the lawsuits.

25. The system of claim 21, wherein the logic in matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits matches at least three of at least the following data elements:

a first name or initial, a last name or initial, a middle name or initial, a home address, a mailing address, a city, a county, a metropolitan area, a state, a zip code initial three digits, a date of birth, a year of birth, or age.

26. The system of claim 21, wherein the litigation information comprises claims corresponding to the parties in the lawsuits and the insurance payment information comprises information concerning payments made to or on behalf of the patients, members or insureds;

and

the logic matches the claims corresponding to the at least one of the parties in the lawsuit with the payments made to the at least one of the patients, members or insureds in the insurance payment information.

27. The system of claim 26, wherein the logic:

analyzes the matching to determine a confidence level associated with the match, the confidence level representing both a confidence that the at least one of the patients, members or insureds in the insurance payment information and the at least one of the parties in the lawsuits are the same person and a confidence that the claims corresponding to the at least one of the parties in the lawsuit is linked with the payments made to the at least one of the patients, members or insureds in the insurance payment information; and

assigns, based on the analyzing the matching, a confidence level to the match.

28. The system of claim 21, wherein the logic:

receives identification information, the identification information received separate from the insurance payment information and the litigation information, the identification information operable to increase a level of confidence that the least one of the patients, members or insureds in the insurance payment information is the same person as the at least one of the parties in the lawsuits; and

links the identification information to one of the at least one of the patients, members or insureds in the insurance payment information or the at least one of the parties in the lawsuits.

29. The system of claim 21, wherein the litigation information comprises claims corresponding to the parties in the lawsuits and the insurance payment information comprises information concerning payments made to or on behalf of the patients, members or insureds, and the logic:

analyzes the claims in the lawsuits to determine a type of suit or claim involved; and

assigns, based on the analysis of the claims in the lawsuits, insurance payment linking information to the claims, the insurance payment linking information operable to map or link claims in the litigation information to the information concerning payments made to or on behalf of the patients, members or insureds.

30. The system of claim 29, wherein the insurance payment linking information is medical procedure codes determined to be applicable to the type of suit or claim involved in the lawsuits and determined to be applicable to subrogation claims or third party claims.

31. The system of claim 30, wherein the medical procedure codes is one of a diagnostic related grouping (DRG) code category, an international classification of disease (ICD) code category, or a current procedural terminology (CPT) code category.

32. The system of claim 30, wherein

the information concerning payments made to or on behalf of the patients, members or insureds includes medical procedure codes;

and

the matching further comprises matching medical procedure codes for one or payments made to or on behalf of one or more patients, members or insureds with medical procedure codes assigned to one or more claims corresponding to one or more parties.

33. The system of claim 29, wherein the logic in analyzing the claims in the litigation information to determine a type of suit or claim involved analyzes one or more of keywords in the lawsuits, a nature of suit for the lawsuit, witnesses, third parties, or defendants in the lawsuit.

34. The system of claim 33, wherein the logic in assigning insurance payment linking information to the claims, for a combination of keywords in the lawsuits, a nature of suit of the lawsuit, witnesses, third parties, or defendants in the lawsuit, assigns insurance payment linking information determined to be applicable to the combination.

35. The system of claim 21, wherein the logic:

analyzes valuation information based on previous processing, resolution, or recovery of third party claims or subrogation claims; and

based on the analysis of the valuation information, assigns a value to the potential third-party claim or a potential subrogation.

36. The system of claim 21, wherein the logic:

analyzes at least one of total paid claims expended for a particular patient, member or insured;

total paid claims incurred during a time period deemed relevant based on an applicable statute of limitation for a corresponding lawsuit;

or paid claims related to a particular medical procedure code determined to be relevant to a type of lawsuit; and

based on the analysis of the valuation information, assigns a value to the potential third-party claim or a potential subrogation.

37. The system of claim 21, wherein the logic:

analyzes the matching to determine a confidence level associated with the match; and

based on the analyzing the matching, assigns a confidence level to the match to predict the likelihood that the least one of the patients, members or insureds in the insurance payment information and the at least one of the parties in the lawsuits are the same.

38. The system of claim 21, wherein the logic in matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits analyzes a service date for the patients, members, or insured to determine that a date a filing of the lawsuit comes after the respective service date for the patients, members or insureds.

39. The system of claim 21, wherein the logic in matching the at least one of the patients, members or insureds in the insurance payment information with the at least one of the parties in the lawsuits analyzes a date of death of the patients, members, or insured to determine that a date a filing of the lawsuit comes after the respective date of death for the patients, members or insureds.