Patent Application Titled “System And Method For Automated Assessment Of Transaction Processing” Published Online (USPTO 20210279809): Patent Application

2021 SEP 27 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- According to news reporting originating from Washington, D.C., by NewsRx journalists, a patent application by the inventor Penner, Andrew (Eagle, ID, US), filed on March 9, 2020, was made available online on September 9, 2021.

No assignee for this patent application has been made.

Reporters obtained the following quote from the background information supplied by the inventors: “Generally, transaction processing systems deployed by third party payer services are configured to process transactions for members of said third party payer services. Examples of third party payer services includes, but are not limited to, insurance services, credit card services, and the like. Transaction processing as referred to herein includes at least analyzing transactions; evaluation of liabilities of a service provider, member of third party payer service and third party payer service; processing of payments; requesting transaction information etc. Examples of transactions may include business transactions such as buying of goods or services, healthcare transactions such as health insurance claims etc. However, the existing transaction processing systems are deterministic in nature and require intensive human intervention in processing a transaction.

“For example: a third party payer service such as a healthcare insurance company, (hereinafter referred to as an “insurer”) may pay for healthcare services received from a service provider including, but not limited to, any person, such as a doctor, pharmacist, etc., or an institution, such as a hospital, clinic, or medical equipment provider, to an insured consumer. The service provider generates a claim which includes details regarding the services rendered, drugs, healthcare supplies, medical equipment, home health, etc. to the insured consumer. Further, the claim is adjudicated by the healthcare insurance company via the transaction processing systems. The transaction processing systems evaluate the liability of one or more parties (e.g., the patient/member, insurer, service provider, etc.) for a given healthcare service based on predefined relationships such as contracts between the insurer and service provider and/or insured member’s healthcare plan. In some instances, an outcome of transaction processing may be issuance of complete payment associated with the claims. In other instances, the outcome of transaction processing may be denying the claims, requesting for more information, requesting for explanations, providing claim adjustment options etc. The entire process of gathering more information, claim adjustments etc. is complex, time consuming and requires human intervention to assess the outcome of transaction processing.

“In light of the above drawbacks, there is a need for a system and method which provides automated assessment of transaction processing. There is a need for a system and method which automatically makes adjustments to an outcome of transaction processing. Further, there is a need for a system and method which significantly reduces human intervention. Furthermore, there is a need for a system and a method which is inexpensive and can be easily integrated with any existing transaction processing systems.”

In addition to obtaining background information on this patent application, NewsRx editors also obtained the inventor’s summary information for this patent application: “In various embodiments of the present invention, a method for automated assessment of transaction processing is provided. The method is implemented by at least one processor executing program instructions stored in a memory. The method comprises categorizing one or more outcomes of transaction processing extracted from one or more messages received from a transaction processing system into predetermined categories. The method further comprises computing probability of one or more predefined parameters associated with a selected category of outcome from the predetermined categories. Furthermore, the method comprises generating one or more actionable(s) based on a comparison between the computed probability of the one or more predefined parameters with corresponding predefined thresholds. Finally, the method comprises executing the one or more actionable(s) using one or more API calls to the transaction processing system.

“In various embodiments of the present invention, a system for automated assessment of transaction processing interfacing with a transaction processing system is provided. The system comprises a memory storing program instructions, a processor configured to execute program instructions stored in the memory, and a transaction outcome assessment engine executed by the processor. The system configured to categorize one or more outcomes of transaction processing extracted from one or more messages received from a transaction processing system into predetermined categories. Further, the system is configured to compute probability of one or more predefined parameters associated with a selected category of outcome from the predetermined categories. Furthermore, the system is configured to generate one or more actionable(s) based on a comparison between the computed probability of the one or more predefined parameters with corresponding predefined thresholds. Yet further, the system is configured to execute the one or more actionable(s) using one or more API calls to the transaction processing system.

“In various embodiments of the present invention, a computer program product is provided. The computer program product comprises a non-transitory computer-readable medium having computer-readable program code stored thereon, the computer-readable program code comprising instructions that, when executed by a processor, cause the processor to categorize one or more outcomes of transaction processing extracted from one or more messages received from a transaction processing system into predetermined categories. Further, probability of one or more predefined parameters associated with a selected category of outcome from the predetermined categories is computed. Furthermore, one or more actionable(s) are generated based on a comparison between the computed probability of the one or more predefined parameters with corresponding predefined thresholds. Yet further, the one or more actionable(s) are executed using one or more API calls to the transaction processing system.”

The claims supplied by the inventors are:

“1. A method for automated assessment of transaction processing, wherein the method is implemented by at least one processor executing program instructions stored in a memory, the method comprising: categorizing, by the processor, one or more outcomes of transaction processing extracted from one or more messages received from a transaction processing system into predetermined categories; computing, by the processor, probability of one or more predefined parameters associated with a selected category of outcome from the predetermined categories; and generating, by the processor, one or more actionable(s) based on a comparison between the computed probability of the one or more predefined parameters with corresponding predefined thresholds.

“2. The method as claimed in claim 1, wherein the one or more actionable(s) are executed using one or more API calls to the transaction processing system.

“3. The method as claimed in claim 1, wherein each of the one or more messages are generated by the transaction processing system on receiving a transaction claim, each of the one or more messages represent information associated with the transaction processing, and comprises at least a transaction claim, liabilities of associated parties and one or more outcomes.

“4. The method as claimed in claim 1, wherein the one or more messages are IOT (Internet of Things) messages.

“5. The method as claimed in claim 3, wherein the transaction claim includes information associated with services rendered by a service provider to a member of a third-party payer service.

“6. The method as claimed in claim 1, wherein the one or more outcomes of transaction processing include issuance of complete payment associated with the transaction claims, denying transaction claims, requesting for more information, requesting explanations, and providing claim adjustment options.

“7. The method as claimed in claim 3, wherein the transaction claim is associated with health care insurance, the one or more outcomes include any of: claim adjustments, partial payments, requesting explanations.

“8. The method as claimed in claim 7, wherein the one or more predetermined categories include claim adjustments, partial payments, and requesting explanations.

“9. The method as claimed in claim 1, wherein the one or more outcomes of transaction processing are categorized using machine leaning techniques based on historical data, wherein the historical data includes previous transaction claims maintained throughout a predefined duration.

“10. The method as claimed in claim 1, wherein the probability of each of the predefined parameters associated with the selected category of outcome is computed using one or more machine learning models, wherein the one or more machine learning models are selected based on the selected category of outcome.

“11. The method as claimed in claim 8, wherein the selected category of outcome is claim adjustment, the one or more predefined parameters include at least one of: leaving of a health plan by the member, appealing against claim by the member or the service provider, and successful claim adjustment.

“12. The method as claimed in claim 1, wherein the one or more actionable(s) are generated if the computed probability of the predefined parameters is greater than or less than the corresponding predefined thresholds.

“13. A system for automated assessment of transaction processing interfacing with a transaction processing system, the system comprising: a memory storing program instructions; a processor configured to execute program instructions stored in the memory; and a transaction outcome assessment engine in communication with the processor and configured to: categorize one or more outcomes of transaction processing extracted from one or more messages received from a transaction processing system into predetermined categories; compute probability of one or more predefined parameters associated with a selected category of outcome from the predetermined categories; generate one or more actionable(s) based on a comparison between the computed probability of the one or more predefined parameters with corresponding predefined thresholds; and execute the one or more actionable(s) using one or more API calls to the transaction processing system.

“14. The system as claimed in claim 13, wherein each of the one or more messages are generated by the transaction processing system on receiving a transaction claim, each of the one or more messages represent information associated with the transaction processing, and comprises at least a transaction claim, liabilities of associated parties and one or more outcomes.

“15. The system as claimed in claim 13, wherein the one or more messages are IOT (Internet of Things) messages.

“16. The system as claimed in claim 14, wherein the transaction claim includes information associated with services rendered by a service provider to a member of a third-party payer service.

“17. The system as claimed in claim 13, wherein the one or more outcomes of transaction processing include issuance of complete payment associated with the transaction claims, denying transaction claims, requesting for more information, requesting explanations, and providing claim adjustment options.

“18. The system as claimed in claim 14, wherein the transaction claim is associated with health care insurance, the one or more outcomes include any of: claim adjustments, partial payments, requesting explanations.

“19. The system as claimed in claim 18, wherein the one or more predetermined categories are any of: claim adjustments, partial payments, and requesting explanations.

“20. The system as claimed in claim 13, wherein the first set of rules comprises using machine learning techniques based on historical data, wherein the historical data includes previous transaction claims maintained throughout a predefined duration.

“21. The system as claimed in claim 13, wherein the probability of each of the predefined parameters associated with the selected category of outcome is computed using one or more machine learning models, wherein the one or more machine learning models are selected based on the selected category of outcome.

“22. The system as claimed in claim 19, wherein the selected category of outcome is claim adjustment, the one or more predefined parameters include at least one of: leaving of a health plan by the member, appealing against claim by the member or the service provider, and successful claim adjustment.

“23. The system as claimed in claim 13, wherein the one or more actionable(s) are generated if the computed probability of the predefined parameters is greater than or less than the corresponding predefined thresholds.

“24. A computer program product comprising: a non-transitory computer-readable medium having computer-readable program code stored thereon, the computer-readable program code comprising instructions that, when executed by a processor, cause the processor to: categorize one or more outcomes of transaction processing extracted from one or more messages received from a transaction processing system into predetermined categories; compute probability of one or more predefined parameters associated with a selected category of outcome from the predetermined categories; generate one or more actionable(s) based on a comparison between the computed probability of the one or more predefined parameters with corresponding predefined thresholds; and execute the one or more actionable(s) using one or more API calls to the transaction processing system.”

For more information, see this patent application: Penner, Andrew. System And Method For Automated Assessment Of Transaction Processing. Filed March 9, 2020 and posted September 9, 2021. Patent URL: https://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=%2220210279809%22.PGNR.&OS=DN/20210279809&RS=DN/20210279809

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