Determining likely outcomes of active insurance claims by calculating and examining aggregated outcomes of matching historic claims

• US 8,630,878 B1
• Filed: 06/17/2011
• Issued: 01/14/2014
• Est. Priority Date: 06/17/2011
• Status: Active Grant

• Current Assignee: Zenith Insurance Company (Fairfax Financial Holdings Limited)
• Original Assignee: Zenith Insurance Co. (Investment Portfolio)
• Inventors: Kravets, Alexandre, Pattiz, Davidson M, Steiner, Vernon L.
• Primary Examiner(s): MILEF, ELDA G
• Application Number:
  US13/163,452
• Time in Patent Office: 942 Days
• Field of Search: 705/4
• US Class Current: 705/4
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems

Abstract

An insurance claim analysis system may generate information indicative of a possible outcome of an active insurance claim. A historic insurance claim information database may hold historic information about historic insurance claims. A database query module may query the historic insurance claim information database for historic insurance claims that match search criteria indicative of one or more aspects of the active insurance claim. A data aggregation module may calculate an aggregate of an aspect of the historic information about the historic insurance claims that match the search criteria or a subset thereof. A report generation module may generate a report that includes the calculated aggregate of the aspect of the historic information.

Claims

1. An insurance claim analysis system for generating information indicative of an outcome of an active insurance claim comprising:

a historic insurance claim information database configured to hold historic information about historic insurance claims;

a database query module that has one or more processors configured to query the historic insurance claim information database for historic insurance claims that match search criteria indicative of one or more aspects of the active insurance claim;

a data aggregation module that has one or more processors configured to calculate an aggregate of an aspect of the historic information about the historic insurance claims that match the search criteria or a subset thereof; and

a report generation module that has one or more processors configured to generate a report that includes the calculated aggregate of the aspect of the historic information

wherein

the historic information about each historic insurance claim includes information indicative of the payment made for medical services that were provided in connection with the historic insurance claim and the type of that medical services, and the calculated aggregate of an aspect of the historic information is an average of the total payments made for a medical service of each type in connection with the historic insurance claims that match the search criteria;

or

the historic information about each historic insurance claim includes a number of disability days;

the calculated aggregate of an assert of the historic information is an average of the number of disability days for the historic insurance claims that match the search criteria;

the historic information about some of the historic insurance claims includes one or more co-morbidity factors, each indicative of a complicating medical factor relating to the historic insurance claim; and

the calculated aggregate of an aspect of the historic information includes;

an average of the number of disability days for the historic insurance claims that match search criteria that includes at least one co-morbidity factor indicative of a complicating medical factor relating to the active insurance claim; and

an average of the number of disability days for the historic insurance claims that match search criteria that does not include any co-morbidity factor indicative of a complicating medical factor relating to the active insurance claim.

2. The insurance claim analysis system of claim 1 further comprising:

a query formulation module that automatically formulates the search criteria; and

a user interface configured to allow a user to modify at least a portion of the search criteria automatically formulated by the query formulation module.

3. The insurance claim analysis system of claim 2 wherein the user interface is configured to allow a user to modify at least a portion of the search criteria by adding one or more “

what if”

criteria to the search query to include as search criteria one or more occurrences that might take place in connection with the active insurance claim.

4. The insurance claim analysis system of claim 1:

further comprising a user interface configured to allow a user to identify a subset of the historic insurance claims that match the search criteria; and

wherein the search criteria includes criteria limiting the search to the identified subset of the historic insurance claims.

5. The insurance claim analysis system of claim 1 wherein:

the historic insurance claim information for each historic insurance claim includes a primary diagnosis category indicative of a related group of diagnoses, one of which has been identified as being primarily responsible for the outcome of the historic insurance claim; and

the search criteria includes a primary diagnosis category indicative of a related group of diagnoses, one of which has been identified as being primarily responsible for the outcome of the active insurance claim.

6. The insurance claim analysis system of claim 5 wherein:

there are multiple ways of determining which diagnosis is primarily responsible for the outcome of the active insurance claim;

the insurance claim analysis system further comprises a user interface configured to allow a user to select one of these multiple ways; and

the primary diagnosis category included with the search criteria is the one that includes the diagnosis determined to be primarily responsible for the outcome of the active insurance claim based on the way selected through the user interface.

7. The insurance claim analysis system of claim 1 wherein:

the historic information about some of the historic insurance claims includes one or more co-morbidity factors, each indicative of a complicating medical factor relating to the historic insurance claim; and

the search criteria includes at least one co-morbidity factor indicative of a complicating medical factor relating to the active insurance claim.

8. The insurance claim analysis system of claim 7 wherein the at least one co-morbidity factor is an inflammatory condition and the search criteria formulated by the query formulation module includes this co-morbidity factor.

9. The insurance claim analysis system of claim 7 wherein the at least one co-morbidity factor is a degenerative condition and the search criteria formulated by the query formulation module includes this co-morbidity factor.

10. The insurance claim analysis system of claim 1 wherein:

the historic information about each historic insurance claim includes an amount of money paid for one or more aspects of the historic insurance claim; and

the calculated aggregate of an aspect of the historic information is an average and/or ranked percentiles of money paid on the one or more aspects of the historic insurance claims that match the search criteria or a subset thereof.

11. The insurance claim analysis system of claim 10 wherein:

the data aggregation module is configured to break down the historic insurance claims that match the search criteria into sub-sets based on the amount of money that was paid on an aspect of the historic insurance claims; and

the calculated aggregate of an aspect of the historic information is an average and/or ranked into percentiles amount of money paid on the aspect of the historic insurance claims for each of the sub-sets.

12. The insurance claim analysis system of claim 10 wherein the calculated aggregate of an aspect of the historic information includes multiple percentages, each percentage being associated with an amount of money, and each percentage indicative of the percentage of claims that match the search criteria or a subset thereof that paid the associated amount of money or less.

13. The insurance claim analysis system of claim 1 wherein:

the historic information about each historic insurance claim includes information indicative of medical services that were provided in connection with the historic insurance claim and the type of that medical services; and

the calculated aggregate of an aspect of the historic information is an average of the number of times a medical service of each type was sought in connection with the historic insurance claims that match the search criteria.

14. The insurance claim analysis system of claim 1 wherein:

the historic information about each historic insurance claim includes information indicative of the payment made for medical services that were provided in connection with the historic insurance claim and the type of that medical services; and

the calculated aggregate of an aspect of the historic information is an average of the total payments made for a medical service of each type in connection with the historic insurance claims that match the search criteria.

15. The insurance claim analysis system of claim 1 wherein:

the historic information about each historic insurance claim includes a number of disability days; and

the calculated aggregate of an aspect of the historic information is an average of the number of disability days for the historic insurance claims that match the search criteria.

16. The insurance claim analysis system of claim 15 wherein:

the historic information about some of the historic insurance claims includes one or more co-morbidity factors, each indicative of a complicating medical factor relating to the historic insurance claim; and

the calculated aggregate of an aspect of the historic information includes;

an average of the number of disability days for the historic insurance claims that match search criteria that includes at least one co-morbidity factor indicative of a complicating medical factor relating to the active insurance claim; and

an average of the number of disability days for the historic insurance claims that match search criteria that does not include any co-morbidity factor indicative of a complicating medical factor relating to the active insurance claim.

17. The insurance claim analysis system of claim 1 wherein:

the historic information about each of some of the historic insurance claims includes information indicative of a change during the course of the historic insurance claim in a primary diagnosis category that has been identified as being primarily responsible for the historic insurance claim outcome; and

the calculated aggregate of an aspect of the historic information is an aggregate of the number of the historic insurance claims that match the search criteria and that have an outcome indicative of no change during the course of the historic insurance claim in a primary diagnosis category.

18. The insurance claim analysis system of claim 1 wherein the data aggregation module is configured to calculate aggregates of multiple aspects of the historic information, each about the historic claims that match the search criteria or a portion thereof.

19. The insurance claim analysis system of claim 1 further comprising a sentinel event notification module that monitors information about active insurance claims and issues an alert to one or more persons each time the information about the active insurance claims indicates the occurrence of a sentinel event that is likely to have a significant effect on the outcome of one of the active insurance claims.

20. Non-transitory, tangible, computer-readable media containing a program of computer instructions configured to implement the following process for generating information indicative of an outcome of an active insurance claim when run in a computer system:

querying a historic insurance claim information database that holds historic information about historic insurance claims for historic insurance claims that match search criteria indicative of one or more aspects of the active insurance claim;

calculating an aggregate of an aspect of the historic information about the historic insurance claims that match the search criteria or a subset thereof; and

generating a report that includes the calculated aggregate of the aspect of the historic information,

wherein;

the historic information about each historic insurance claim includes information indicative of the payment made for medical services that were provided in connection with the historic insurance claim and the type of that medical services, and the calculated aggregate of an aspect of the historic information is an average of the total payments made for a medical service of each type in connection with the historic insurance claims that match the search criteria;

or

the historic information about each historic insurance claim includes a number of disability days;

the calculated aggregate of an aspect of the historic information is an average of the number of disability days for the historic insurance claims that match the search criteria;

the historic information about some of the historic insurance claims includes one or more co-morbidity factors, each indicative of a complicating medical factor relating to the historic insurance claim; and

the calculated aggregate of an aspect of the historic information includes;

an average of the number of disability days for the historic insurance claims that match search criteria that includes at least one co-morbidity factor indicative of a complicating medical factor relating to the active insurance claim; and

an average of the number of disability days for the historic insurance claims that match search criteria that does not include any co-morbidity factor indicative of a complicating medical factor relating to the active insurance claim.