Computer system for applying predictive model to determine and indeterminate data
First Claim
1. A computer system comprising:
- a data storage module configured to receive, store, and provide access to indeterminate data and determinate data corresponding to historical claim transactions and to current claim transactions, and data indicative of categories of claims that are highly unlikely to be questionable;
a computer processor configured to;
receive determinate data corresponding to the historical claim transactions and the current claim transactions;
receive raw indeterminate data corresponding to the historical claim transactions and the current claim transactions;
extract, from the raw indeterminate data by an indeterminate data capture module, indeterminate data comprising at least one of claim handler notes, claim handler audio files, witness notes, witness audio files, claimant notes, and claimant audio files, the indeterminate data capture module including a natural language processing application to mine opinions from narrative text notes and a speech recognition application to analyze audio files to detect a speaker'"'"'s state of mind;
train, by a model training component, a predictive model component based on the determinate data and the extracted indeterminate data related to the historical claim transactions, thereby providing a trained predictive model component;
adapt the predictive model component to changing patterns of questionable claim transactions by periodically updating the predictive model component based on new determinate data and new extracted indeterminate data;
compare, by a screening module, a current claim transaction to the data indicative of categories of claims that are highly unlikely to be questionable and categorize, based on the comparing, each of said current claim transactions as one of a current claim suitable for predictive analysis when the current claim transaction does not correspond to the categories of claims that are highly unlikely to be questionable and a current claim not suitable for predictive analysis when the current claim transaction corresponds to at least one of the categories of claims that are highly unlikely to be questionable;
determine, by the predictive model component coupled to the data storage module and based on the indeterminate data and the determinate data, whether to identify a one of said current claim transactions categorized as suitable for predictive analysis for referral to an investigation unit;
an output device, coupled to the computer processor, configured to output an indication of whether said one of said current claim transactions should be referred to the investigation unit, said output generated in response to application of data for said one of said current claim transactions to the trained predictive model component and said screening module; and
a routing module configured to direct workflow corresponding to said one of said current claim transactions based on the output from the output device, to one of an investigative analyst computer and a field investigator computer.
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Abstract
A computer system includes a data storage module. The computer system also includes an indeterminate data capture module. The data storage module receives, stores, and provides access to both determinate data and indeterminate data that was captured by the indeterminate data capture module. The computer system also includes a computer processor and a program memory. The computer processor executes programmed instructions and stores and retrieves the data stored in the data storage module. The data stored in the data storage module is related to historical claim transactions and current claim transactions. A predictive model component is coupled to the data storage module, and determines whether to refer a current claim transaction to an investigation unit. A model training component is coupled to the computer processor and functions to train the predictive model.
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Citations
34 Claims
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1. A computer system comprising:
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a data storage module configured to receive, store, and provide access to indeterminate data and determinate data corresponding to historical claim transactions and to current claim transactions, and data indicative of categories of claims that are highly unlikely to be questionable; a computer processor configured to; receive determinate data corresponding to the historical claim transactions and the current claim transactions; receive raw indeterminate data corresponding to the historical claim transactions and the current claim transactions; extract, from the raw indeterminate data by an indeterminate data capture module, indeterminate data comprising at least one of claim handler notes, claim handler audio files, witness notes, witness audio files, claimant notes, and claimant audio files, the indeterminate data capture module including a natural language processing application to mine opinions from narrative text notes and a speech recognition application to analyze audio files to detect a speaker'"'"'s state of mind; train, by a model training component, a predictive model component based on the determinate data and the extracted indeterminate data related to the historical claim transactions, thereby providing a trained predictive model component; adapt the predictive model component to changing patterns of questionable claim transactions by periodically updating the predictive model component based on new determinate data and new extracted indeterminate data; compare, by a screening module, a current claim transaction to the data indicative of categories of claims that are highly unlikely to be questionable and categorize, based on the comparing, each of said current claim transactions as one of a current claim suitable for predictive analysis when the current claim transaction does not correspond to the categories of claims that are highly unlikely to be questionable and a current claim not suitable for predictive analysis when the current claim transaction corresponds to at least one of the categories of claims that are highly unlikely to be questionable; determine, by the predictive model component coupled to the data storage module and based on the indeterminate data and the determinate data, whether to identify a one of said current claim transactions categorized as suitable for predictive analysis for referral to an investigation unit; an output device, coupled to the computer processor, configured to output an indication of whether said one of said current claim transactions should be referred to the investigation unit, said output generated in response to application of data for said one of said current claim transactions to the trained predictive model component and said screening module; and a routing module configured to direct workflow corresponding to said one of said current claim transactions based on the output from the output device, to one of an investigative analyst computer and a field investigator computer. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19)
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20. A computer system comprising:
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a data storage unit configured to receive, store, and provide access to historical claim data and current claim data, the current claim data representing a plurality of current claim transactions, and said data storage unit also data indicative of categories of claims that are highly unlikely to be questionable; an indeterminate data capture module configured to extract, from the raw indeterminate data, indeterminate data comprising at least one of claim handler notes, claim handler audio files, witness notes, witness audio files, claimant notes, and claimant audio files, the indeterminate data capture module including a natural language processing application to mine opinions from narrative text notes and a speech recognition application to analyze audio files to detect a speaker'"'"'s state of mind; a computer processor configured to; compare, by a screening module, a current claim transaction to the data indicative of categories of claims that are highly unlikely to be questionable and to categorize, based on the comparison, each of the current claim transactions as one of a current claim transaction suitable for predictive analysis when the current claim transaction does not correspond to the categories of claims that are highly unlikely to be questionable and a current claim transaction not suitable for predictive analysis when the current claim transaction corresponds to at least one of the categories of claims that are highly unlikely to be questionable; train, by a model training component, a predictive model based on the indeterminate data and the determinate data for each current claim transaction categorized as suitable for predictive analysis in the data storage unit and to provide a respective output for each current claim transaction represented by the current claim data, the respective output indicating whether said each current claim transaction should be referred to an investigation unit; adapt the predictive model component to changing patterns of questionable claim transactions by periodically updating the predictive model component based on new determinate data and new extracted indeterminate data; and route, by a routing component, responsive to the respective output for each of the current claim transactions, selective ones of the current claim transactions to the investigation unit. - View Dependent Claims (21, 22, 23, 24, 25, 26, 27, 28)
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29. A method of operating a computer system, the method comprising:
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receiving determinate data corresponding to the historical claim transactions and the current claim transactions; receiving raw indeterminate data corresponding to the historical claim transactions and the current claim transactions; extracting, from the raw indeterminate data by an indeterminate data capture module, indeterminate data comprising at least one of claim handler notes, claim handler audio files, witness notes, witness audio files, claimant notes, and claimant audio files, the indeterminate data capture module including a natural language processing application to mine opinions from narrative text notes and a speech recognition application to analyze audio files to detect a speaker'"'"'s state of mind; storing, in a computer storage unit, the determinate data and the information extracted from the indeterminate data as historical claim data; using the historical claim data to train and verify a predictive model, the predictive model for evaluating claim transactions to determine whether to refer the claim transactions to an investigation unit; adapting the predictive model component to changing patterns of questionable claim transactions by periodically updating the predictive model component based on new determinate data and new extracted indeterminate data; using the plurality of input devices to provide determinate data and indeterminate data for current claim transactions; processing the indeterminate data for the current claim transactions to extract information from the indeterminate data for the current claim transactions; storing, in the computer storage unit, the determinate data for the current claim transactions and the information extracted from the indeterminate data for the current claim transactions; identifying at least a first current claim transaction as one suitable for analysis by the trained and verified predictive model, wherein the first current claim transaction comprises a claim corresponding to at least one category of claims that are highly unlikely to be questionable; applying the trained and verified predictive model to the determinate data for the at least first current claim transaction and to the information extracted from the indeterminate data for the at least first current claim transaction, to generate an output for the at least first current claim transaction; and selectively routing the at least first current claim transaction to an investigative unit based on the outputs generated by the predictive model. - View Dependent Claims (30, 31, 32, 33, 34)
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Specification