SYSTEM AND METHOD FOR CALCULATING ESTIMATED CLAIM COSTS

• US 20130290037A1
• Filed: 06/04/2013
• Published: 10/31/2013
• Est. Priority Date: 05/14/2009
• 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: Hu, Wangyang, Maurer, Kathleen F., McLaughlin, Kelly J.
• Granted Patent: US 8,620,698 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/06375 Prediction of business process outcome or impact based on a proposed change
• CPC Class Codes: G06Q 10/087 Inventory or stock management, e.g. order filling, procurement or balancing against orders
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients

Abstract

A computer system includes a data storage device. The data storage module receives, stores, and provides access to historical claim data. A categorical aggregation component comprising program instructions stored in a program memory provides categorized and aggregated historical claim data by identifying claim categories based on the historical claim data, each of the one or more claim categories associated with a respective set of claim characteristics, identifying claims of the historical claim data associated with one of the claim categories, assigning each identified claim to one of a plurality of total severity ranges based on the total severity of the identified claim, and determining an average cost per claim year for claims of each total severity range when executed by a computer processor.

Claims

1. A computer system for estimating insurance claim severity, comprising:

a first data storage device storing data relating to a plurality of insurance claims, the data comprising a plurality of characteristics associated with each of the plurality of insurance claims and total claim cost data associated with each of the claims;

a computer processor in communication with the data storage device; and

a program memory in communication with the computer processor, storing computer-readable instructions, which, when executed by the computer processor, cause the computer processor to;

determine a first set of claim characteristics;

determine a plurality of first claims of the plurality of insurance claims, the first claims each having the claim characteristics of the first set;

determine a statistical profile of the claim cost data of the first claims based on the claim cost data associated with each of the first claims;

determine whether the determined statistical profile meets profile criteria;

responsive to determining that the determined statistical profile meets the profile criteria, associate the first set of claim characteristics with a first claim category;

associate each of the first claims to one of a plurality of total cost ranges based on the total cost data associated with the first claims;

determine an average cost per claim year associated with each of a plurality of expense categories for the first claims associated with each of the total cost ranges; and

store in a second data storage device the determined average cost per claim year data; and

a display device in communication with the second data storage device configured to display the determined average cost per claim year data.

2. The computer system of claim 1, wherein the computer-readable instructions, which, when executed by the computer processor, further cause the computer processor to:

determine a second set of claim characteristics, the second set of claim characteristics being a subset of the first set of claim characteristics;

identify second claims of the plurality of stored claims, the second claims having associated therewith the second set of claim characteristics;

determine a statistical profile of the total cost data associated with the second claims;

responsive to determining that the determined statistical profile meets the profile criteria, associate the second set of claim characteristics with a second claim category, the second claim category being a subcategory of the first claim category.

3. The computer system of claim 2, wherein the first claim category is non-traumatic back surgery, the second claim category is cervical, and further comprising a further second claim category being a subset of the first claim category, the further second claim category being lumbar.

4. The computer system of claim 3, further comprising subcategories fusion and no fusion of the second claim category lumbar.

5. The computer system of claim 3, further comprising subcategories fusion and no fusion of the second claim category cervical.

6. The computer system of claim 2, further comprising a claim evaluation component, the claim evaluation component comprising:

a third data storage device storing data relating to one or more current insurance claims;

a second computer processor in communication with the third data storage device;

a second program memory in communication with the second computer processor, storing second computer-readable instructions, which, when executed by the second computer processor, cause the second computer processor to;

based on the stored data relating to one of the current insurance claims, associate the current claim with one of the categories; and

calculate, based on data from claims associated with the one of the categories, an estimated total cost of the one of the current insurance claims for each of a plurality of outcome scenarios; and

a display device configured to display a graphical representation of the estimated total cost of the one of the current insurance claims for each of the plurality of outcome scenarios.

7. The computer system of claim 6, wherein a first one of the plurality of outcome scenarios comprises a first range of total cost;

and a second one of the plurality of outcome scenarios comprises a second range of total cost lower than the first range of total cost.

8. The computer system of claim 6, wherein the second computer-readable instructions, when executed by the second computer processor, further cause the second computer processor to determine a likelihood associated with each of the outcome scenarios based on the claim data associated with the category associated with the one of the current claims.

9. The computer system of claim 6, further comprising an adjuster terminal display device in communication with the second computer processor, and wherein the second computer-readable instructions, when executed by the second computer processor, further cause the second computer processor to output to the adjuster terminal display device data indicative of an estimated cost and a likelihood associated with each of the outcome scenarios.

10. The computer system of claim 9, wherein an adjuster terminal is further configured to receive and execute adjuster instructions to perform one or more of:

suggesting treatment options, forwarding the current claim to a medical personnel terminal, forwarding the current claim to a claim processing terminal, or re-assigning the current claim.

11. The computer system of claim 10, further comprising a medical personnel terminal, and a medical hardware server, wherein the medical personnel terminal is configured to receive the current claim forwarded by the adjuster terminal and to provide medical services associated with the current claim using medical application programs furnished by the medical hardware server.

12. A computer-implemented method for estimating insurance claim severity, comprising:

accessing, by a computer processor, a first data storage device storing data relating to a plurality of insurance claims, the data comprising a plurality of characteristics associated with each of the plurality of insurance claims and total claim cost data associated with each of the claims;

determining, by the computer processor, a first set of claim characteristics;

determining, by the computer processor, a plurality of first claims of the plurality of insurance claims, the first claims each having the claim characteristics of the first set;

determining, by the computer processor, a statistical profile of the claim cost data of the first claims based on the claim cost data associated with each of the first claims;

determining, by the computer processor, whether the determined statistical profile meets profile criteria;

responsive to determining that the determined statistical profile meets the profile criteria, associating, by the computer processor, the first set of claim characteristics with a first claim category;

associating, by the computer processor, each of the first claims to one of a plurality of total cost ranges based on the total cost data associated with the first claims;

determining, by the computer processor, an average cost per claim year associated with each of a plurality of expense categories for the first claims associated with each of the total cost ranges;

storing, in a second data storage device, the determined average cost per claim year data; and

displaying, by a display device in communication with the second data storage, device, the determined average cost per claim year data.

13. The computer-implemented method of claim 12, further comprising:

determining by the computer processor a second set of claim characteristics, the second set of claim characteristics being a subset of the first set of claim characteristics;

identifying by the computer processor second claims of the plurality of stored claims, the second claims having associated therewith the second set of claim characteristics;

determining by the computer processor a statistical profile of the total CLAIM cost data associated with the second claims;

responsive to determining that the determined statistical profile meets the profile criteria, associating by the computer processor the second set of claim characteristics with a second claim category, the second claim category being a subcategory of the first claim category.

14. The computer-implemented method of claim 13, further comprising:

accessing by a computer processor of a claim evaluation component a third data storage device storing data relating to one or more current insurance claims;

based on the stored data relating to one of the current insurance claims, associating by the claim evaluation component computer processor the current claim with one of the categories;

calculating, by the claim evaluation component computer processor, based on data from claims associated with the one of the categories, an estimated total cost of the one of the current insurance claims for each of a plurality of outcome scenarios; and

displaying by a display device a graphical representation of the estimated total cost of the one of the current insurance claims for each of the plurality of outcome scenarios.

15. The computer-implemented method of claim 14, further comprising:

outputting by the claim evaluation component computer processor to a display device of an adjuster terminal in communication data indicative of a estimated total claim cost and a likelihood associated with each of the outcome scenarios; and

displaying by the adjuster terminal display device the data indicative of an estimated cost and a likelihood associated with each of the outcome scenarios.

16. The computer-implemented method of claim 15, further comprising:

receiving and executing, by the adjuster terminal, instructions to perform one or more of;

suggesting treatment options, forwarding the current claim to a medical personnel terminal, forwarding the current claim to a claim processing terminal, or re-assigning the current claim.

17. The computer-implemented method of claim 16, further comprising:

receiving, by a medical personnel terminal, the current claim forwarded by the adjuster terminal; and

providing, by the medical personnel terminal, medical services associated with the current claim using medical application programs furnished by a medical hardware server.

18. A non-transitory computer-readable medium having computer-readable instructions stored thereon, which instructions, when executed by a computer processor, cause the computer processor to:

access a first data storage device storing data relating to a plurality of insurance claims, the data comprising a plurality of characteristics associated with each of the plurality of insurance claims and total claim cost data associated with each of the claims;

determine a first set of claim characteristics;

determine a plurality of first claims of the plurality of insurance claims, the first claims each having the claim characteristics of the first set;

determine a statistical profile of the claim cost data of the first claims based on the claim cost data associated with each of the first claims;

determine whether the determined statistical profile meets profile criteria;

responsive to determining that the determined statistical profile meets the profile criteria, associate the first set of claim characteristics with a first claim category;

associate each of the first claims to one of a plurality of total cost ranges based on the total cost data associated with the first claims;

determine an average cost per claim year associated with each of a plurality of expense categories for the first claims associated with each of the total cost ranges; and

output to a second data storage device, for storage, the determined average cost per claim year data.

19. The non-transitory computer-readable medium of claim 18, wherein the instructions, when executed by the computer processor, further cause the computer processor to:

determine a second set of claim characteristics, the second set of claim characteristics being a subset of the first set of claim characteristics;

identify second claims of the plurality of stored claims, the second claims having associated therewith the second set of claim characteristics;

determine a statistical profile of the total cost data associated with the second claims;

responsive to determining that the determined statistical profile meets the profile criteria, associate the second set of claim characteristics with a second claim category, the second claim category being a subcategory of the first claim category.

20. The non-transitory computer-readable medium of claim 19, wherein the first claim category is non-traumatic back surgery, the second claim category is cervical, and further comprising a further second claim category being a subset of the first claim category, the further second claim category being lumbar.