ENRICHED SYSTEM FOR SUSPICIOUS INTERACTION RECORD DETECTION

• US 20160301706A1
• Filed: 02/25/2016
• Published: 10/13/2016
• Est. Priority Date: 04/07/2015
• Status: Active Grant

• Current Assignee: Experian Health, Inc. (Experian plc)
• Original Assignee: Passport Health Communications (Experian plc)
• Inventors: Katz, Elazar
• Granted Patent: US 10,187,399 B2
• Time in Patent Office: Days
• US Class Current: 1/1
• CPC Class Codes: H04L 63/1408 by monitoring network traffic monitoring network traffic per se H04L43/00
• CPC Class Codes: H04W 12/02 Protecting privacy or anonymity, e.g. protecting personally identifiable information [PII]
• CPC Class Codes: H04W 12/63 Location-dependent; Proximity-dependent

Abstract

Systems and methods for improved detection of fraud, waste, and abuse are provided, based on the analysis of enriched relationships and aggregated metrics thereof. An enriched relationship record associates patient and provider information to provide an enhanced view of patient data, provider data, and interaction data for a given entity. Aggregated metrics provide an enhanced view of a particular entity'"'"'s activities based on the entity'"'"'s interactions with other entities and data and metadata from the related entities'"'"' enriched relationship records. The enriched relationship records and aggregated metrics may be used to audit the entity and produce a report indicative of suspicion levels for the entity engaging in fraud, waste, or abuse.

Claims

1. A method for improving efficiency for a computing device used to detect entities engaged in suspicious activity, comprising:

collecting interaction records;

parsing the interaction records to determine a first entity, a second entity, and an interaction between the first entity and the second entity for each of the interaction records;

analyzing the parsed interaction records to produce an aggregated metric based on a statistical baseline of interactions between the first entity and the second entity;

comparing the interaction records that include a given first entity against the aggregated metric according to a set of auditing rules to determine a suspicion level for the given first entity;

generating a report based on the suspicion level; and

transmitting the report to a third party.

2. The method of claim 1, wherein the statistical baseline is a mean value for all of the first entities parsed from the interaction records of the interaction between the first entity and each of the second entities with which the first entity has interacted.

3. The method of claim 1, wherein the statistical baseline is a mean value for all of the first entities that share a selected feature parsed from the interaction records of the interaction between the first entity and each of the second entities with which the first entity has interacted.

4. The method of claim 1, wherein the interaction records that include the given first entity are aggregated into an enriched relationship record, wherein the enriched relationship record includes average values and overall values related to the given first entity parsed from the interaction records.

5. The method of claim 1, wherein the interaction records that include the given first entity are compared against the aggregated metric according to thresholds included in the set of auditing rules to determine whether the given first entity passes the set of auditing rules.

6. The method of claim 5, further comprising:

when the given first entity does not pass the set of auditing rules according to the thresholds, transmitting the report to the given first entity, wherein the report includes a request for additional information from the given first entity.

7. The method of claim 6, wherein the request for additional information includes a response window, which specifies a period of time in which the given first entity is allowed to respond to the request for additional information.

8. A system for improving efficiency for a computing device used to detect entities engaged in suspicious activity, comprising:

a processor; and

a memory storage device including instructions, which when executed by the processor cause the system to provide;

a relationship enricher, operable to collect information related to the entities and interactions between the entities, and further operable to process the collected information to produce an enriched relationship record for a given entity;

an aggregator, operable to statistically analyze a plurality of enriched relationship records to produce a statistical baseline for a property of the plurality of enriched relationship records, and further operable to produce an aggregated metric for the plurality of enriched relationship records based on the statistical baseline and a statistical rule;

an auditing engine, operable to compare the enriched relationship record for the given entity and the aggregated metric against auditing rules to produce a suspicion level for the given entity; and

a reporter, operable to generate a report based on the suspicion level, wherein the reporter is further operable to transmit the report to a payor.

9. The system of claim 8, wherein the report is operable to affect a frequency of future reviews of interaction records that include the given entity.

10. The system of claim 8, wherein the suspicion level for the given entity is set so that the given entity is initially under suspicion, wherein repeated comparisons of the enriched relationship record for the given entity and the aggregated metric against auditing rules updates the suspicion level.

11. The system of claim 8, wherein when the suspicion level indicates that the given entity is under suspicion, the reporter is further operable to transmit the report to the payor before a payment is released to the given entity from the payor.

12. The system of claim 8, wherein when the suspicion level indicates that the given entity is under suspicion, the reporter is further operable to transmit a request for additional information to the given entity before a payment is released.

13. The system of claim 12, wherein the request for additional information includes a response window, which specifies a period of time in which the given entity is allowed to respond to the request for additional information.

14. The system of claim 12, wherein the auditing engine is further operable to receive a response to the request for additional information from the given entity, and compare the response to the enriched relationship record to determine whether the response includes inconsistent data and thereby increase the suspicion level for the given entity.

15. A system for improving efficiency for a computing device used to detect entities engaged in suspicious activity, comprising:

a processor that generates an enriched relationship record for an entity by collecting information related to patients, providers, and interactions between patients and providers that include the entity;

an enriched relationships database for storing the enriched relationship record; and

a rules database for storing a statistical rule;

wherein the processor further produces a statistical baseline by statistically analyzing a plurality of enriched relationship records to produce an aggregated metric for the plurality of enriched relationship records based on the statistical rule, wherein the aggregated metric includes a threshold; and

wherein the processor further compares the enriched relationship record to the threshold of the aggregated metric to determine whether the enriched relationship record is outside of the threshold of the aggregated metric, and when it is determined that the enriched relationship record is outside of the threshold of the aggregated metric, generate a report indicating that the entity is suspicious, and transmit the report.

16. The system of claim 15, wherein the report is transmitted to a payor via at least one of:

a cellular interface;

a telephone interface; and

a network interface.

17. The system of claim 15, wherein the report is transmitted to the entity and includes a request for additional information to verify a consistency of information supplied by the entity.

18. The system of claim 15, wherein the entity is a person being provided services.

19. The system of claim 15, wherein the entity is a party providing services and requesting payment therefor.

20. The system of claim 15, wherein when the threshold is met, a suspicion level for the entity is adjusted and wherein the threshold sets when the suspicion level is lowered for the entity and when the suspicion level is raised for the entity.