Patent Application Titled “Systems And Methods For Predicting Personalization And Intelligent Routing” Published Online (USPTO 20220109757): UnitedHealth Group Incorporated

2022 APR 21 (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 inventors Babjack, Destiny (Bethel Park, PA, US); Bargman, Eric (St. Louis Park, MN, US); Groat, Tina (Frisco, TX, US); Howell, Peter D. (St. Paul, MN, US); Kelly, Tom (Shorewood, MN, US); Kumar, Mayank (Noida, IN); Long, Sandra (St. Paul, MN, US); McNattin, Sean (Dayton, MN, US); Sundberg, Lawrence Kevin (Big Lake, MN, US); Tan, Kevin (Minnetonka, MN, US), filed on October 14, 2021, was made available online on April 7, 2022.

The assignee for this patent application is UnitedHealth Group Incorporated (Minnetonka, Minnesota, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “One in five families in the United States has a child with special needs. In a given year, a family with a special needs member submits thirteen times as many claims as families without special needs members. Those families also spend approximately eighty-one times more out of pocket and see five times as many physicians, consuming critical and expensive resources. Often the source of the special needs arise from a rare and/or ambiguous disease that medical professionals, healthcare advocates and others have difficulty classifying or treating. The technical difficulty of diagnosing or classifying a member’s condition or need leads to a member being on a diagnostic odyssey in search of an accurate diagnosis and access to specialized services available for that diagnosis. Traveling on a diagnostic odyssey due to a rare disease or the inability to properly diagnose a disease can lead to service denials, require appeals, higher out-of-pocket expenses, numerous visits to medical providers, and other onerous and detrimental consequences. Technical and financial resources are diverted or unnecessarily consumed/wasted.

“Trying to navigate the complex landscape of service or care delivery, and social service providers, while balancing the care of family members with special needs, can leave families feeling frustrated, confused, financially stressed, tired, and in some situations hopeless. While families that have members with special needs use and rely on the healthcare system significantly more than any other population, often times those families are not equipped to traverse the complexities and intricacies of the system in a manner that maximizes the intended benefits offered to such families.

“Further complicating access to appropriate healthcare services is the lack of intelligent routing of member calls and requests for information. Individuals contact organizations on a daily basis for a variety of reasons. In the past, organization representatives received and routed calls based on verbal caller input. Nowadays, however, organizations routinely have networks with automated systems that receive and route calls within the network. The automated systems sometimes use natural language or intelligent routing technologies that route incoming calls using data and/or voice input of a caller.

“Current technologies may use caller ID and natural language technologies to route a call to a specific representative group of an organization. However, current technologies are not tailored to the complexities of special needs, and do not provide organization representatives with intelligent routing coupled with broad access to caller data in real-time. Known systems are generally not designed and configured in a manner to adequately capture and translate the service needs of a special needs caller while routing calls and data.

“For example, callers typically have concerns or issues that require analysis by many points of contact across an organization. These points of contact are often disparate and disconnected, requiring a caller to call many areas of an organization or the caller being re-directed several times before having their problems adequately addressed by appropriate resources within the organization.”

In addition to obtaining background information on this patent application, NewsRx editors also obtained the inventors’ summary information for this patent application: “The present disclosure generally provides an intelligent and data-driven system, tailored to special needs requirements, for predicting, identifying, tracking and routing requests for information from members of an organization. Systems and methods according to the disclosure solve the technical problems associated with limited intelligence and data association and provide access to information and intelligent routing for members of an organization with special needs or considerations. The system and method of the present disclosure is configured to predict, detect, alert and intelligently route to provide information to members of an organization who have special needs.

“In one aspect, the disclosure provides for intelligent analysis and routing of calls, such as those processed through Interactive Voice Response (IVR) systems, within an organization. Improved systems and methods according to the disclosure use an automatic number identification processor (ANI), an improved conversation management processor (CM), and natural language processor to provide an organization member with a single organization point-of-contact within an optimized network to address all the member’s needs. The member and their household are identified using ANI or other authentication techniques, the caller’s expressed, explicit need is identified using natural language processing techniques, and the member’s implicit, anticipated needs are derived by the CM using associated data sources and a variety of independent analytic variables.

“The CM includes a specially configured and tailored rules engine that filters data inputs from several data sources. The CM specifically applies rules to the data and determines the implicit or anticipated level, e.g., basic, complex, or clinical in nature, of call messaging presentation and representative/advocate support most appropriate for the member.

“A member may contact the organization on behalf of themselves or another member of their household. Thus, the present disclosure provides for identification of the needs of multiple identifiable individuals of the member’s household, thereby preventing the need to transfer the member to various organization advocates until all of the member’s needs are addressed or resolved. Specifically, the systems and methodology disclosed herein enable the single organization point-of-contact within the optimized network to address all of a member’s needs by providing the organization advocate with an exhaustive up-to-date record and tailored graphical user interface (GUI) encompassing data associated with all individuals of the member’s household.

“The improved conversation management processor of the present disclosure provides a member engagement solution that maintains a holistic, contextual record for each member, thereby allowing for quick and effective placement of a member with an appropriate organization advocate. This prevents various member complaints experienced under present technologies. The disclosed system and method avoids dropping of information, i.e. information collected during an interactive voice response not being transferred to the ultimate organization advocate. The disclosed system and method avoids long and confusing prompts and inadequate menu options for directing the member to the appropriate organization advocate. Similarly, the disclosed system and method avoids the ultimate advocate misunderstanding the context of the member’s call.

“The specific, sophisticated analytics performed by the intelligent conversation management processor on the member data translates complex member data into consumable data that organization advocates have at their fingertips when interacting with a member. In various embodiments, for example the system and method of the disclosure implemented in a healthcare association context, the analytics described herein enable the aggregation of several types of data, e.g., healthcare claims history data, demographics data, healthcare expenses data, behavioral data, geographic data, provider availability data, and the like.

“One aspect of the improved conversation management system of the present disclosure provides advanced techniques for identification and notification of members of an organization in need of specialized services. According to a further aspect of the disclosure, a system may include intelligent routing capabilities configured to detect and predict when an individual or group of individuals, such as a family, may be on a diagnostic odyssey or be ambiguously diagnosed. Using the data-driven and rules-based classification of a member as ambiguously diagnosed, a further aspect of the present disclosure allows for the conversation management processor to more effectively establish communication between advocates (those working for and with the organization) and members with special needs. Aspects of the present system may provide for a communications system configured to proactively alert or otherwise establish communication between members requiring special needs and the organizational advocates assisting them.

“A further aspect of the present disclosure provides a holistic GUI presented to the advocate. Information displayed in the GUI, including the reason for the member’s call, allows the advocate to quickly address the member’s needs and offer suggestions to the member, e.g., in a healthcare association context, opportunities for the member to improve their use of the healthcare industry and programs that may help the member improve their health and well-being.

“The disclosed intelligent routing techniques streamline and simplify inbound communication from members of an organization such as healthcare plan members. The disclosed intelligent analysis and routing techniques use several data points to connect the member with an organization advocate most appropriately suited to address the member’s concerns. The disclosed systems and methods provide improvements over present technologies by utilizing an improved conversation management processor, within a highly secure networked computing environment(s), that applies specific, tailored rules/logic to data from multiple sources.”

The claims supplied by the inventors are:

“1.-18. (canceled)

“19. A network for intelligently routing an organization’s member to an organization representative, comprising: an authentication processor configured to authenticate the member using automatic identification; a processor configured to analyze spoken content of the member to determine a specialized need of the member; and a conversation management processor configured to: determine routing based on at least one of a member’s referral score and an effort risk score, a conversation management data storage in communication with the conversation management processor; and a graphical user interface in communication with the conversation management processor and the conversation management data storage.

“20. The network of claim 19 wherein the member’s referral score is derived from multiple variables.

“21. The network of claim 20 wherein the multiple variables include at least two of the following: pharmacy first fill data, treatment referral data, pharmacy value score, an impact pro cost risk score, a monetized value, a household opportunity value, a comprehensive medication review program data, and a cost risk score.

“22. The secure network of claim 19 wherein the conversation management processor further determines the member’s effort risk score based on at least one of: diagnosis data, demographic data, and outstanding claim data.

“23. The secure network of claim 22 wherein the effort risk score is based on most frequently occurring diagnosis categories for a member’s household.

“24. A method for intelligently routing a member of an organization to an organization representative, comprising: receiving a communication from a member; determining an identity of the member; determining the member’s effort risk score; comparing the member’s referral score with a program eligibility threshold; and routing the member to an organization representative if the member’s referral score meets the program eligibility threshold.

“25. The method of claim 24, in which the effort risk score is based on most frequently occurring diagnosis categories for a member’s household.

“26. The method of claim 25, in which the effort risk score is assigned within a predetermined range based on the member’s household data satisfying at least one program’s eligibility requirements.

“27. The method of claim 25 in which the effort risk score determines a tier of organization representative receiving the routing of the communication from the member.

“28. A system for establishing communication between an organization’s member and an organization representative, comprising: a conversation management processor configured to: receive validation from an application gateway if the organization’s member communication is appropriate for routing; interact with a communication management data storage to retrieve and update data pertaining to the organization’s member; check the organization’s member profile data; and calculate routing rules based on the thresholds.

“29. The system of claim 28 wherein the conversation management processor validates the organization’s member profile using extension tables.

“30. The system of claim 29 in which the extension tables house member household routing data.”

For more information, see this patent application: Babjack, Destiny; Bargman, Eric; Groat, Tina; Howell, Peter D.; Kelly, Tom; Kumar, Mayank; Long, Sandra; McNattin, Sean; Sundberg, Lawrence Kevin; Tan, Kevin. Systems And Methods For Predicting Personalization And Intelligent Routing. Filed October 14, 2021 and posted April 7, 2022. 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=%2220220109757%22.PGNR.&OS=DN/20220109757&RS=DN/20220109757

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