System and method for rules driven insurance claim processing

• US 9,940,675 B2
• Filed: 10/11/2013
• Issued: 04/10/2018
• Est. Priority Date: 10/11/2013
• Status: Active Grant

• Current Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Original Assignee: Hartford Fire Insurance Company (The Hartford Financial Services Group, Inc.)
• Inventors: Kinney, John, Pace, Vittoria, Ruszala, Anthony C., Snow, III, Thomas L., Emory, Larry B., Burns, Robert K.
• Primary Examiner(s): Niquette, Robert R
• Application Number:
  US14/051,703
• Publication Number:
  US 20150106129A1
• Time in Patent Office: 1,642 Days
• Field of Search: None
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

According to some embodiments, data is received indicative of a plurality of insurance claims submitted in connection with insurance policies. A rules driven claim processing engine may then apply a first exclusion filter to the received plurality of claims, wherein the first exclusion filter operates to remove claims from the received plurality of claims to create a first subset of claims. A second exclusion filter may then be applied to the first subset of claims, wherein the second exclusion filter operates to remove claims from the first subset of claims to create a second subset of claims. It may then be automatically arranged for the second subset of claims to be processed via an expedited claim processing workflow.

Claims

1. A system, comprising:

an intake computer system configured to receive, from a plurality of remote computing devices, data records corresponding to submissions received at a rate of thousands of submissions per year from the plurality of remote computing devices;

a plurality of handler computing devices; and

a rules driven processing engine for sequentially applying a selected combination of filters to the data records to effect an expedited processing data flow which reduces a number of data records processed according to a normal processing data flow, the rules driven processing engine interposed between the intake computer system and the plurality of handler computing devices to communicatively couple said rules driven processing engine, said intake system, and said plurality of handler computing devices, said rules driven processing engine configured to;

receive, by a processing engine communication device from the intake computer system, one or more electronic files including the data records;

reduce the data records to generate a first subset of reduced data records by application of a first filter rule to the data records that removes each of the data records that does not correspond to a valid policy;

responsive to reduction of the data records and generation of the first subset of reduced data records, reduce the first subset of data records to generate a second subset of reduced data records by application of a second filter rule to the first subset of reduced data records that removes each of the data records of the first subset of reduced data records that corresponds to pre-determined legal jurisdictions;

responsive to reduction of the first subset of reduced data records and generation of the second subset of reduced data records, reduce the second subset of reduced data records to generate a third subset of reduced data records by application of a third filter rule to the second subset of reduced data records that removes each of the data records of the second subset of reduced data records that corresponds to a pre-determined injury type, wherein the third subset of reduced data records comprises a final subset of reduced data records;

automatically transmit the data records removed by sequential application of the selected combination of filters to a normal workflow module of a workflow management system configured to assign each of the removed data records to a handler based upon a complexity of a claim corresponding to the data record and handler workload, and transmit an electronic file corresponding to each of the removed data records to one of the plurality of handler computing devices, each corresponding to one of the assigned handlers, wherein the data records removed by sequential application of the selected combination of filters comprise a reduced subset of the data records received from the intake computer system;

automatically transmit the final subset of reduced data records not removed by sequential application of the selected combination of filters to an expedited workflow module of the workflow management system, the expedited workflow module configured to;

sort data records of the final subset of reduced data records into a first expedited data record subset including each of the data records of the final subset of reduced data records which has a corresponding payment value below a pre-determined threshold and a second expedited data record subset including each of the data records of the final subset of reduced data records which has a corresponding payment value above the pre-determined threshold;

generate a payment for each of the data records of the first expedited data record subset, without each such data record being transmitted to one of the plurality of handler computing devices for processing by a handler according to the normal workflow module of the workflow management system; and

transmit each of the data records of the second expedited data record subset to one of the plurality of handler computing devices for processing by a handler who specializes in processing of data records transmitted to the expedited workflow module; and

output, to a team leader computing device, a display including data indicative of the final subset of reduced data records.

2. The system of claim 1, wherein the rules driven processing engine is further configured to:

responsive to reduction of the second subset of reduced data records and generation of the third subset of reduced data records, reduce the third subset of reduced data records to generate a fourth subset of reduced data records by application of a fourth filter rule to the third subset of reduced data records that removes each of the data records of the third subset of reduced data records that corresponds to a pre-determined policy type; and

automatically transmit the data records removed by application of the fourth filter rule to the normal workflow module of a workflow management system;

wherein the fourth subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

3. The system of claim 2, wherein the rules driven processing engine is further configured to:

responsive to reduction of the third subset of reduced data records and generation of the fourth subset of reduced data records, reduce the fourth subset of reduced data records to generate a fifth subset of reduced data records by application of a fifth filter rule to the fourth subset of reduced data records that removes each of the data records of the fourth subset of reduced data records that corresponds to a pre-determined threshold monetary amount; and

automatically transmit the data records removed by application of the fifth filter rule to the normal workflow module of a workflow management system;

wherein the fifth subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

4. The system of claim 3, wherein the rules driven processing engine is further configured to:

responsive to reduction of the fourth subset of reduced data records and generation of the fifth subset of reduced data records, reduce the fifth subset of reduced data records to generate a sixth subset of reduced data records by application of a sixth filter rule to the fifth subset of reduced data records that removes each of the data records of the fifth subset of reduced data records that corresponds to a pre-determined liability determination; and

automatically transmit the data records removed by application of the sixth filter rule to the normal workflow module of a workflow management system;

wherein the sixth subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

5. The system of claim 4, wherein the rules driven processing engine is further configured to:

responsive to reduction of the fifth subset of reduced data records and generation of the sixth subset of reduced data records, reduce the sixth subset of reduced data records to generate a seventh subset of reduced data records by application of a seventh filter rule to the sixth subset of reduced data records that removes each of the data records of the sixth subset of reduced data records that corresponds to a pre-determined geographic location; and

automatically transmit the data records removed by application of the seventh filter rule to the normal workflow module of a workflow management system;

wherein the seventh subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

6. The system of claim 1, wherein the rules driven processing engine is further configured to automatically transmit information about the third subset of data records to at least one of:

(i) an email server, (ii) a report generator, and (iii) a calendar application.

7. The system of claim 1, wherein application of at least one of the first filter rule, the second filter rule, and the third filter rule corresponds to receipt of data indicative of a First Notice Of Loss.

8. The system of claim 1, wherein at least one of the first filter rule, the second filter rule, and the third filter rule is based at least in part on a predictive model trained by:

applying one or both of a variable association data reduction process and a granularity reduction process to historical claim processing data records to generate reduced historical claim processing data records and reduce a dimensionality of the historical claim processing data records; and

training, based upon the reduced historical claim processing data records, the predictive model to generate exclusion filters for assignment of future data records corresponding to workers'"'"' compensation claims;

wherein the predictive model is implemented by application of at least one of;

(i) a neural network, (ii) a Bayesian network, (iii) a Hidden Markov model, (iv) an expert system, (v) a decision tree, (vi) a collection of decision trees, (vii) a support vector machine, and (viii) weighted factors.

9. A system, comprising:

an intake computer system configured to receive, from a plurality of remote computing devices, data records corresponding to submissions received at a rate of thousands of submissions per year from the plurality of remote computing devices;

a plurality of handler computing devices; and

a rules driven processing engine for sequentially applying a selected combination of filters to the data records to effect an expedited processing data flow which reduces a number of data records processed according to a normal processing data flow, the rules driven processing engine interposed between the intake computer system and the plurality of handler computing devices to communicatively couple said rules driven processing engine, said intake system, and said plurality of handler computing devices, said rules driven processing engine configured to;

receive, by a processing engine communication device from the intake computer system, one or more electronic files including the data records;

reduce the data records to generate a first subset of reduced data records by application of a first filter rule to the data records that removes each of the data records that does not correspond to a valid policy;

responsive to reduction of the data records generation of the first subset of reduced data records, reduce the first subset of data records to generate a second subset of reduced data records by application of a second filter rule to the first subset of reduced data records that removes each of the data records of the first subset of reduced data records that corresponds to pre-determined legal jurisdictions;

responsive to reduction of the first subset of reduced data records and generation of the second subset of reduced data records, reduce the second subset of reduced data records to generate a third subset of reduced data records by application of a third filter rule to the second subset of reduced data records that removes each of the data records of the second subset of reduced data records that corresponds to a pre-determined injury type, wherein the third subset of reduced data records comprises a final subset of reduced data records;

automatically transmit the data records removed by sequential application of the selected combination of filters to a normal workflow module of a workflow management system configured to assign each of the removed data records to a handler based upon a complexity of a claim corresponding to the data record and handler workload, and transmit an electronic file corresponding to each of the removed data records to one of the plurality of handler computing devices, each corresponding to one of the assigned handlers, wherein the data records removed by sequential application of the selected combination of filters comprise a reduced subset of the data records received from the intake computer system; and

automatically transmit the final subset of reduced data records not removed by sequential application of the selected combination of filters to an expedited workflow module of the workflow management system, the expedited workflow module configured to generate a payment for each of the data records of the final subset of reduced data records having a corresponding payment value below a pre-determined threshold, without each such data record being transmitted to one of the plurality of handler computing devices for processing by a handler according to the normal workflow module of the workflow management system.

10. The system of claim 9, wherein the rules driven processing engine is further configured to:

responsive to reduction of the second subset of reduced data records and generation of the third subset of reduced data records, reduce the third subset of reduced data records to generate a fourth subset of reduced data records by application of a fourth filter rule to the third subset of reduced data records that removes each of the data records of the third subset of reduced data records that corresponds to a pre-determined policy type; and

automatically transmit the data records removed by application of the fourth filter rule to the normal workflow module of a workflow management system;

wherein the fourth subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

11. The system of claim 9, wherein the rules driven processing engine is further configured to:

responsive to reduction of the second subset of reduced data records and generation of the third subset of reduced data records, reduce the third subset of reduced data records to generate a fourth subset of reduced data records by application of a fourth filter rule to the third subset of reduced data records that removes each of the data records of the third subset of reduced data records that corresponds to a pre-determined threshold monetary amount; and

automatically transmit the data records removed by application of the fourth filter rule to the normal workflow module of a workflow management system;

wherein the fourth subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

12. The system of claim 9, wherein the rules driven processing engine is further configured to:

responsive to reduction of the second subset of reduced data records and generation of the third subset of reduced data records, reduce the third subset of reduced data records to generate a fourth subset of reduced data records by application of a fourth filter rule to the third subset of reduced data records that removes each of the data records of the third subset of reduced data records that corresponds to a pre-determined liability determination; and

automatically transmit the data records removed by application of the fourth filter rule to the normal workflow module of a workflow management system;

wherein the fourth subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

13. The system of claim 9, wherein the rules driven claims processing engine is further configured to:

responsive to reduction of the second subset of reduced data records and generation of the third subset of reduced data records, reduce the third subset of reduced data records to generate a fourth subset of reduced data records by application of a fourth filter rule to the third subset of reduced data records that removes each of the data records of the third subset of reduced data records that corresponds to a pre-determined geographic location; and

automatically transmit the data records removed by application of the fourth filter rule to the normal workflow module of a workflow management system;

wherein the fourth subset of reduced data records comprises the final subset of reduced data records that is transmitted to the expedited workflow module of the workflow management system.

14. The system of claim 9, wherein the rules driven processing engine is further configured to automatically transmit information about the third subset of data records to at least one of:

(i) an email server, (ii) a report generator, and (iii) a calendar application.

15. The system of claim 9, wherein data corresponding to the data records is received by the intake computer system via at least one of:

(i) a submitted paper claim, (ii) a telephone call center, and (iii) an online claim submission web page.

16. The system of claim 9, wherein the rules driven processing engine is further configured to output an indication of the third subset of data records to a team leader computing device.

17. The system of claim 9, wherein application of at least one of the first filter rule, the second filter rule, and the third filter rule corresponds to receipt of data indicative of a First Notice Of Loss.

18. The system of claim 9, wherein at least one of the first filter rule, the second filter rule, and the third filter rule is based at least in part on a predictive model trained by:

applying one or both of a variable association data reduction process and a granularity reduction process to historical claim processing data records to generate reduced historical claim processing data records and reduce a dimensionality of the historical claim processing data records; and

training, based upon the reduced historical claim processing data records, the predictive model to generate exclusion filters for assignment of future data records corresponding to workers'"'"' compensation claims.

19. The system of claim 18, wherein the predictive model is implemented by application of at least one of:

(i) a neural network, (ii) a Bayesian network, (iii) a Hidden Markov model, (iv) an expert system, (v) a decision tree, (vi) a collection of decision trees, (vii) a support vector machine, and (viii) weighted factors.