Patent Application Titled “Methods And Systems For Anamoly Detection In Dental Insurance Claim Submissions” Published Online (USPTO 20210012426)

2021 JAN 28 (NewsRx) -- By a News Reporter-Staff News Editor at Health Policy and Law Daily -- According to news reporting originating from Washington, D.C., by NewsRx journalists, a patent application by the inventors Brooks, Mark (Gregory, MI); McMillan, Sean (Ann Arbor, MI); Rock, David (Saline, MI); Schlosser, Steven (Gregory, MI), filed on June 18, 2020, was made available online on January 14, 2021.

The assignee for this patent application is NovoDynamics Inc. (Ann Arbor, Michigan, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “The present invention relates generally to methods and systems for screening and managing dental insurance claim forms. More particularly, the present invention relates to methods and systems for detecting duplications and other anomalies among large numbers of dental insurance claim forms.

“Healthcare expenditures in the United States are currently very large and expected to rise as the population ages and treatment options increase. Recent CMS reports set 2017 healthcare spending at $3.5 trillion and 2026 spending estimates at $5.7 trillion, which represents an annual growth rate of 5% over the next decade.

“With spending at these levels, it is not surprising that healthcare insurance fraud occurs with significant frequency. In 2012, a RAND Corporation study estimated 10% (or $98 billion) of Medicare and Medicaid expenditures were paid to fraudulent claimants. Applying this rate to the entire health system, shows this level of fraud would amount to $350 billion or more in 2018 despite ongoing efforts by the Federal Government to reduce or eliminate insurance fraud.

“National dental expenditures are an important component of overall healthcare spending in the United States. The American Dental Association (ADA) reported in 2017 that dental spending was $124 billion or about 3.7% of all healthcare spending. As with overall healthcare spending, dental insurance fraud is a continuing problem, one estimated to occur at a rate near that of overall healthcare insurance fraud. Assuming a dental insurance fraud rate of 8%, fraudulent claims would amount to about $10 billion in 2018. With loss amounts this large, additional efforts to combat insurance fraud are warranted.

“Dental insurance fraud can take a variety of forms, including billing for services not performed; billing for services that are not necessary; up-coding procedures to receive overpayment; altering dates of service to obtain coverage; unbundling or improper use of codes; and, of most interest to the present invention, falsifying patient identities and records to obtain payments for patients who have not received services.

“While dental insurers have developed automated assessment procedures to reduce losses due to fraud, these procedures must still rely on expert clinicians to assess image information (e.g., radiographs and photographs.

“It is therefore an object of the present invention to provide computer-implemented and other automated approaches to extracting information from dental images that can be used improve current insurer claim assessment procedures. In particular, it would be useful to provide methods and tools for the automated analysis of dental images to assist in detecting fraudulent dental insurance claims.

“U.S. Pat. No. 9,940,677 describes a computer-implemented system and method for detecting property insurance fraud. U.S. Pat. No. 9,710,599 describes a computer-implemented system and method for managing radiographic images being assessed as part of insurance claims. See also, US20180039733 and US20100145734.”

In addition to obtaining background information on this patent application, NewsRx editors also obtained the inventors’ summary information for this patent application: “The present invention provides computer-assisted methods and systems for helping to identify fraudulent dental insurance claims. In particular, the methods and systems of the present invention can lessen the need to rely on expert clinicians to evaluate dental insurance claims 1) by using computer-implemented tools to assess image-based dental insurance claim information; (2) by increasing the number of dental insurance claims that can have their image-based information assessed in a cost-effective manner; (3) by increasing the fraud detection rate; and, (4) by increasing the efficiency of expert clinician review by prioritizing claims for review.

“In a first aspect, the present invention provides a method for detecting duplication anomalies in a set of patient dental insurance records submitted as part of a dental insurance claim. The method will be performed on a processor where the processor will be associated with a reference database which contains information derived from dental insurance records previously submitted with prior dental insurance claims from a population of patients. The processor and the database may be co-located in a common facility or installation in order to maintain patient privacy, but in other instances may be separated or distributed among two, three, four, five or more locations and/or have at least portions of the processor capability and/or the reference database storage located in the cloud.

“Patient dental insurance records typically contain numerous documents and may include, but are not limited to, images of a patient’s teeth, patient probe depth charts, patient correspondence, and the like. Patient dental insurance records may be submitted by a dentist, patient, or other submitting party in a digital or non-digital form. Non-digital records are typically scanned or otherwise digitized for evaluation and processing by the methods described herein.

“Once the patient records have been received in or converted to a digitized form, a hash code will be generated from the digitized image. If a digitized image contains multiple views of a patient’s teeth, in addition to the original image, the individual views are extracted from the image as separate images, and a hash code is generated for each image.

“The hash codes are then compared against a database which includes hash codes generated from previous dental insurance claims. If two hash codes are identical or determined to be sufficiently similar by calculating a Hamming distance score, the dental records are flagged as anomalies and additional screening of the full records is performed. To be flagged as needing further screening in accordance with the present invention, the calculated Hamming distance score between two hash codes must reach a minimum threshold value and the minimum threshold value may be adjusted based on anomaly selection criteria, such as the success rate at which the automated screening is able to identify fraudulent records and/or the failure rate at which the automated screening flags legitimate patient claims for further screening. Flagging may comprise identifying only the anomalous patient insurance claim or identifying both the anomalous patient insurance claim and the records represented by the hash code in the reference data base with the Hamming distance below the defined threshold value.

“It will be appreciated that once the hash codes have been generated, those scores are then incorporated into the reference database so that future patient record submissions can be compared against a continuously updated reference database.

“To reduce the time required to compare two hash codes, some patient record images or extracted teeth views may be classified, and the classification information may be stored in a reference database and associated with its corresponding hash code. For example, a patient record image may be classified as a patient depth chart, a radiograph, correspondence or the like. Extracted teeth views may be classified as a bitewing image, a periapical image, a panoramic image or the like. Hash code comparison time between recently submitted patient dental insurance records and the reference database is reduced if only hash codes from similarly classified images are compared.

“In a second aspect, the present invention provides methods for establishing and maintaining a reference database including hash codes representing sets of historic patient dental insurance records submitted in support of previous dental insurance claims. The hash codes may be used for comparison against future patient dental records which have been processed similarly to generate hash codes.

“In a third aspect of the present invention, reference databases are provided which comprise a plurality of hash codes representing a plurality of sets of patient dental insurance records submitted as part of a plurality of dental insurance claims. The patient database may be maintained on a server, in the cloud, or in any other hardware system that allows maintenance and periodic updating of the data in the database. The hash codes may be generated by any of the methods and processes described elsewhere herein.”

The claims supplied by the inventors are:

“1. A method performed on a processor for detecting duplication anomalies in a set of patient dental insurance records submitted as part of a dental insurance claim, said method comprising: providing at least some of the patient dental insurance records as digital document(s); generating at least one hash code representing each digital document from the provided patient dental insurance records; calculating a Hamming distance between the generated document hash code and each of a plurality of hash codes in a database which includes hash codes representing documents from previous dental insurance claims; and flagging the dental insurance documents for further review if the calculated Hamming distance between a document hash code and the database hash code differ by less than a threshold amount.

“2. A method as in claim 1, wherein the patient dental insurance records include radiographic images.

“3. A method as in claim 2, wherein the radiographic images contain multiple teeth view images, further comprising extracting one or more individual tooth images and generating the hash code for each individual tooth image.

“4. A method as in claim 3, wherein the radiographic images are selected from a group consisting of a bitewing image, a periapical image, or a panoramic image.

“5. A method as in claim 1, wherein providing the dental insurance records comprises providing additional patient documents including at least some of a patient probe depth-chart, patient correspondence, and one or more patient photographs as digitized documents.

“6. A method as in claim 1, further comprising classifying the hash code for each digitized document according to a type of dental insurance record so that the hash code for any patient document can be compared only against hash codes for similar document types in the database.

“7. A method as in claim 1, wherein providing at least some of the patient dental insurance records comprises digitizing at least some of dental insurance forms and images.

“8. A method as in claim 1, wherein at least some of the patient dental insurance records are in a digitized format when provided.

“9. A method for establishing and maintaining a reference database including hash codes representing sets of patient dental insurance records submitted as part of a dental insurance claim, said method comprising: providing at least some of the patient dental insurance records as digital document(s); generating at least one hash code for representing each digital document from the provided patient dental insurance records; and saving the generated hash codes in the reference database.

“10. A method as in claim 9, wherein the patient dental insurance records include radiographic images.

“11. A method as in claim 10, wherein the radiographic images contain multiple teeth view images, further comprising extracting one or more individual tooth images and generating the hash code for each individual tooth image.

“12. A method as in claim 11, wherein the radiographic images are selected from a group consisting of a bitewing image, a periapical image, or a panoramic image.

“13. A method as in claim 9, wherein providing the dental insurance records comprises providing additional patient documents including at least some of a patient probe depth-chart, patient correspondence, and one or more patient photographs as digitized documents.

“14. A method as in claim 9, further comprising classifying digitized documents according to a type of dental insurance record so that the hash code for any patient document can be stored with similar document types in the reference database.

“15. A method as in claim 9, wherein providing at least some of the patient dental insurance records comprises digitizing at least some of dental insurance forms and images.

“16. A method as in claim 9, wherein at least some of the patient dental insurance records are in a digitized format when provided.

“17. A method performed on a processor for detecting duplication anomalies in a set of patient dental insurance records submitted as part of a dental insurance claim, said method comprising: calculating Hamming distances between hash codes representing individual documents from the set of patient dental insurance records and hash codes from a reference database established and maintained as set forth in any claim 9; and flagging the dental insurance forms for further review if the calculated Hamming Distance between the hash code of the submitted patient insurance records and the hash codes stored within the reference database differ by less than a threshold amount.

“18. A reference database comprising a plurality of hash codes representing a plurality of sets of patient dental insurance records submitted as part of a plurality of dental insurance claims.

“19. The reference database of claim 18, wherein said reference database is established and maintained by: providing at least some of the patient dental insurance records in a form including at least one digitized document; generating at least one hash code for each digitized document; saving the generated hash code(s) in the reference database.”

For more information, see this patent application: Brooks, Mark; McMillan, Sean; Rock, David; Schlosser, Steven. Methods And Systems For Anamoly Detection In Dental Insurance Claim Submissions. Filed June 18, 2020 and posted January 14, 2021. Patent URL: http://appft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PG01&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.html&r=1&f=G&l=50&s1=%2220210012426%22.PGNR.&OS=DN/20210012426&RS=DN/20210012426

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