COMPUTER SYSTEM AND METHOD FOR PROCESSING DATA RELATING TO NURSE INTERVENTION PROGRAM DECISIONS

• US 20130346097A1
• Filed: 08/27/2013
• Published: 12/26/2013
• Est. Priority Date: 12/09/2009
• 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: Adams, Jonathan Kaleb, Gawel, Ryan A., Pagano, Joseph D.
• Granted Patent: US 9,218,592 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06N 20/00 Machine learning
• CPC Class Codes: G06N 5/045 Explanation of inference; Explainable artificial intelligence [XAI]; Interpretable artificial intelligence
• CPC Class Codes: G06Q 10/06 Resources, workflows, human or project management; Enterprise or organisation planning; Enterprise or organisation modelling
• CPC Class Codes: G06Q 10/1057 Benefits or employee welfare, e.g. insurance, holiday or retirement packages
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems

Abstract

According to some embodiments, historical claim data may be stored in a computer storage unit. The historical claim data may be used to train and verify a predictive model, the predictive model being associated with an evaluation of claim transactions to determine whether to refer each claim transactions to a nurse intervention program. Data for current claim transactions may be processed, and the trained and verified predictive model may be applied to the data for the current claim transactions to generate a respective output for each of the current claim transactions. Some of the current claim transactions may be selectively routed to a case management center associated with the nurse intervention program based on the outputs generated by the predictive model.

Claims

1. A computer system for data processing relating to a nurse intervention program for insurance claims, comprising:

a nurse intervention program referral determination computer system, comprising;

a data storage device storing data indicative of a trained predictive model configured to determine, based on insurance claim transaction data, a nurse intervention program score, the score indicative of a likelihood of suitability for nurse intervention of insurance claim transactions;

one or more computer processors in communication with the data storage device; and

a program memory, coupled to the one or more computer processors, storing program instruction steps for execution by the one or more computer processors, the program instructions, when executed by the one or more computer processors, causing the one or more computer processors to;

receive data indicative of an insurance claim transaction, the data comprising at least injury data, employee occupation data, and co-morbidity data;

apply the predictive model to the received data indicative of an insurance claim transaction to determine a nurse intervention program score, the predictive model being responsive to values of each of injury, occupation, and co-morbidity data; and

based on the nurse intervention program score, determine a positive or negative nurse intervention program recommendation;

responsive to a positive nurse intervention program recommendation, output data relating to the received insurance claim transaction; and

a nurse intervention program computer in communication with the nurse intervention program referral determination computer system and configured to receive the data relating to the received insurance claim transaction output responsive to the positive nurse intervention program recommendation.

2. The computer system of claim 1, wherein the co-morbidity data comprises at least one of (i) alcohol related co-morbidity information, (ii) drug related co-morbidity information, (iii) tobacco related co-morbidity information, (iv) arthritis related co-morbidity information, (v) diabetes related co-morbidity information, or (vi) obesity related co-morbidity information.

3. The computer system of claim 1, wherein the received data indicative of an insurance claim transaction further comprises prior injury data, and the predictive model is further responsive to values of prior injury data.

4. The computer system of claim 1, wherein the received data indicative of an insurance claim transaction further comprises reserve data, and the predictive model is further responsive to values of reserve data.

5. The computer system of claim 1, wherein the program instructions, when executed by the one or more computer processors, further cause the one or more computer processors to:

after receipt of the data indicative of an insurance claim transaction, and prior to applying the predictive model to the received data, determine whether the insurance claim transaction is in a category that does not qualify for consideration for referral to a nurse intervention program; and

apply the predictive model to the received data indicative of an insurance claim transaction only responsive to determining that the insurance claim transaction is not in a category that does not qualify for consideration for referral to a nurse intervention program.

6. The computer system of claim 5, wherein a category of insurance claim transaction that does not qualify for consideration for referral to a nurse intervention program comprises a workers compensation claim arising from loss of life on the job.

7. The computer system of claim 1, wherein the program instructions, when executed by the one or more computer processors, further cause the one or more computer processors to:

determine a positive or negative nurse intervention program recommendation by comparing the nurse intervention program score to a threshold value.

8. The computer system of claim 1, wherein the program instructions, when executed by the one or more computer processors, further cause the one or more computer processors to:

include, in the output data, data causing the received insurance claim transaction to be queued in a case manager queue according to the nurse intervention program score.

9. The computer system of claim 1, wherein the insurance claim transactions are worker'"'"'s compensation claims.

10. The computer system of claim 1, wherein the insurance claim transactions are bodily injury claims.

11. A computer-implemented method for processing data related to a nurse intervention program for insurance claims, comprising:

storing, in a data storage device, data indicative of a trained predictive model configured to determine, based on insurance claim transaction data, a nurse intervention program score, the score indicative of a likelihood of suitability for nurse intervention of the received insurance claim transactions;

receiving, by one or more computer processors of a nurse intervention program referral determination computer system, data indicative of an insurance claim transaction, the data comprising at least injury data, employee occupation data, and co-morbidity data;

applying, by the one or more computer processors of the nurse intervention program referral determination computer system, the predictive model to the received data indicative of an insurance claim transaction to determine a nurse intervention program score, the predictive model being responsive to values of each of injury, occupation, and co-morbidity data; and

based on the nurse intervention program score, determining, by the one or more computer processors of the nurse intervention program referral determination computer system, a positive or negative nurse intervention program recommendation;

responsive to a positive nurse intervention program recommendation, outputting, by the one or more computer processors of the nurse intervention program referral determination computer system, data relating to the received insurance claim transaction; and

receiving, by a nurse intervention program computer in communication with the nurse intervention program referral determination computer system, the output data relating to the received insurance claim transaction.

12. The computer-implemented method of claim 11, wherein the co-morbidity data comprises at least one of (i) alcohol related co-morbidity information, (ii) drug related co-morbidity information, (iii) tobacco related co-morbidity information, (iv) arthritis related co-morbidity information, (v) diabetes related co-morbidity information, or (vi) obesity related co-morbidity information.

13. The computer-implemented method of claim 11, wherein the received data indicative of an insurance claim transaction further comprises prior injury data, and the predictive model is further responsive to values of prior injury data.

14. The computer-implemented method of claim 11, further comprising:

after receipt of the data indicative of an insurance claim transaction, and prior to applying the predictive model to the received data, determining whether the insurance claim transaction is in a category that does not qualify for consideration for referral to a nurse intervention program; and

assigning the insurance claim transaction data to a queue of transactions for application of a predictive model only responsive to determining that the insurance claim transaction is not in a category that does not qualify for consideration for referral to a nurse intervention program.

15. The computer-implemented method of claim 14, wherein a category of claims that does not qualify for consideration for referral to a nurse intervention program is a category comprising claims of an employer account not providing for nurse intervention.

16. The computer-implemented method of claim 11, wherein the predictive model is configured to weight key factors more highly than other factors, and wherein key factors for a back injury comprise nature of injury data and part of body data.

17. A non-transitory computer-readable medium, storing computer-executable instructions thereon, which instructions, when executed by one or more computer processors, cause the one or more processors to:

receive data indicative of an insurance claim transaction, the data comprising at least injury data, employee occupation data, and co-morbidity data;

apply a trained predictive model to the received data indicative of an insurance claim transaction to determine a nurse intervention program score, the score being indicative of a likelihood of suitability for nurse intervention of insurance claim transactions, and the predictive model being responsive to values of each of POB, NOI, occupation, and co-morbidity data; and

based on the nurse intervention program score, determine a positive or negative nurse intervention program recommendation; and

responsive to a positive nurse intervention program recommendation, output data relating to the received insurance claim transaction.

18. The non-transitory computer-readable medium of claim 17, wherein the instructions, when executed by one or more processors, further cause the one or more processors to:

provide a notification to a claim handler to whom the insurance claim transaction was assigned of referral of the insurance claim transaction to a nurse intervention program.

19. The non-transitory computer-readable medium of claim 17, wherein the injury data comprises at least part of body injured data and nature of injury data.

20. The non-transitory computer-readable medium of claim 17, wherein the nurse intervention program score has binary values, one value of the score indicating that the insurance claim transaction is suitable for a nurse intervention program, and the other value of the score indicating that the insurance claim transaction is not suitable for a nurse intervention program.