Patent Issued for Medical Claims Lead Summary Report Generation (USPTO 10,372,879)

2019 AUG 21 (NewsRx) -- By a News Reporter-Staff News Editor at Information Technology Business Daily -- According to news reporting originating from Alexandria, Virginia, by NewsRx journalists, a patent by the inventors Subramanian, Gokul (McLean, VA); Agarwal, Rahul (New York City, NY); Seaton, William (New York City, NY); Wu, Diane (Palo Alto, CA), filed on December 21, 2015, was published online on August 19, 2019.

The assignee for this patent, patent number 10,372,879, is Palantir Technologies Inc. (Palo Alto, California, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “The approaches described in this section are approaches that could be pursued, but not necessarily approaches that have been previously conceived or pursued. Therefore, unless otherwise indicated, it should not be assumed that any of the approaches described in this section qualify as prior art merely by virtue of their inclusion in this section.

“Healthcare fraud accounts for an estimated $60-80 billion dollars/year in waste. Some estimate that the damages constitute 3-10% of all healthcare expenditures. One source of fraud is prescription drug fraud. Examples of prescription fraud include forging prescriptions, altering prescriptions, stealing prescription pads, calling in prescriptions or using online pharmacies, doctor/pharmacy shopping (for example, going to multiple doctors, emergency rooms, or pharmacies and seeking prescriptions while faking symptoms such as migraine headaches, toothaches, cancer, psychiatric disorders, and attention deficit disorder, or having deliberately injured oneself), going across state lines to seek fulfillment at multiple pharmacies, refilling prescriptions before ninety days, and so forth. Prescription fraud primarily occurs at retailer pharmacies, and primarily with narcotics, anti-anxiety medications, muscle relaxants, and hypnotics.

“Other sources of fraud include insurance claims fraud such as a provider charging more than peers for services, a provider billing for more tests per patient than peers, a provider billing for unlikely or unnecessary medical procedures, upcoding of services or billing for the most expensive of options, upcoding of equipment or billing for a more expensive item and delivering a lower cost item, consistently billing for high cost medical equipment, such as Durable Medical Equipment, billing for procedures or services not provided, filing duplicate claims that bill for the same service on two separate occasions, unbundling a group of services so that the services billed one at a time yield more compensation than if they had been bundled together, kickbacks from referrals, transportation fraud, collecting money from multiple insurance providers, using surgical modifiers to increase reimbursement, fraud involving viatical health and life insurance, nursing home fraud such as lack of services rendered or services rendered by non-licensed professionals, and so forth.

“Prescription claims, doctor office claims, medical procedure claims, hospital claims, medical equipment claims, and other medical claims (collectively referred to as medical claims or healthcare claims) may number in the millions or billions per year. And each medical claim may include numerous types of data, such as billing codes, patient identifier, location, service provider identifier, service date, and the like. Thus, while databases of medical claims contain vast amount of information, selectively mining the available information for useful purposes is not a trivial task.

“Techniques for detecting medical claims fraud may include automated and manual processes. For example, although potentially fraudulent medical claims (referred to as fraud leads) can be identified using automated techniques, whether or not to take further action on particular ones of the fraud leads (e.g., investigate, deny reimbursement, notify authorities, pursue remedial action, hold for additional available information, etc.) may require human analysis and decision-making. When provided with a list of fraud leads, however, persons (referred to as fraud analysts) tasked with analyzing or vetting these identified leads may be overwhelmed by the large number of leads in the list. Lists may also lack context and/or useful information for fraud analysts to make an accurate and/or efficient assessment about whether to take further action on particular ones of the identified leads.”

In addition to obtaining background information on this patent, NewsRx editors also obtained the inventors’ summary information for this patent: “The appended claims may serve to summarize the invention.”

The claims supplied by the inventors are:

“What is claimed is:

“1. A computer-implemented method comprising: in response to receiving lead data identifying an entity associated with a health care claim relating to suspected fraud, determining one or more data sources that were used to identify the entity or the suspected fraud by determining two or more sources from among a plurality of sources; applying two or more weight values, respectively, to each of the two or more sources; based on two or more of the weight values, determining whether each of the two or more sources is at or above a threshold; accessing a pre-defined subset corresponding to each of the two or more of the sources that satisfies the threshold; determining a plurality of data display elements based on the pre-defined subset, wherein each of the plurality of data display elements is configured to cause displaying health care claims data associated with the entity in a designated format; applying a weight to each of the plurality of data display elements based upon historical levels of user interaction with each of the plurality of data display elements displayed within historical lead summary reports; determining whether each of the weighted plurality of data display elements is at or above at least one threshold; combining the obtained pre-defined subsets to form a subset of the plurality of data display elements, wherein each data display element in the subset satisfies the at least one threshold; automatically obtaining, from a data repository, specific health care claims data associated with the entity for each of the plurality of data display elements in the subset; generating a lead summary report associated with the entity using a report template, the subset, and the obtained specific health care claims data; wherein the method is performed by one or more computing devices.

“2. The method of claim 1, further comprising automatically updating the lead summary report in response to detecting a change in the specific health care claims data.

“3. The method of claim 1, further comprising: receiving input from a client computing device specifying a change to the lead summary report; responsive to the input, updating the lead summary report with the change.

“4. The method of claim 3, wherein the input comprises adding notes or comments to the lead summary report, assigning the lead summary report to a particular user for assessment, or selection of a feedback option.

“5. The method of claim 1, further comprising creating and digitally storing one or more evidentiary documents based on the lead summary report, in response to an input from a client computing device specifying to preserve the lead summary report at a certain point in time.

“6. The method of claim 1, wherein each of the one or more sources comprises a fraud detection model or scheme.

“7. The method of claim 1, wherein the determining which one or more sources comprises determining that a source is unknown and that the suspected fraud was identified by a third party computer system, and wherein the subset comprises a particular subset that is pre-defined for use when the source is unknown.

“8. The method of claim 1, wherein the determining which one or more sources comprises determining a particular source from among a plurality of sources, and wherein the subset comprises a particular subset that is pre-defined for the particular source.

“9. The method of claim 1, wherein the subset comprises a combination of a particular subset that is pre-defined for each of the two or more sources.

“10. A computer system comprising: one or more databases including a plurality of health care claims data and a plurality of data display elements; a report generator component, at least partially implemented by computing hardware, coupled to the one or more databases and comprising one or more sequences of instructions which when executed by one or more processors are programmed to perform: in response to receiving lead data identifying an entity associated with a health care claim relating to suspected fraud, determining one or more data sources that were used to identify the entity or the suspected fraud by determining two or more sources from among a plurality of sources; applying two or more weight values, respectively, to each of the two or more sources; based on two or more of the weight values, determining whether each of the two or more sources is at or above a threshold; accessing a pre-defined subset corresponding to each of the two or more of the sources that satisfies the threshold; determining a plurality of data display elements based on the pre-defined subset, wherein each of the plurality of data display elements is configured to cause displaying health care claims data associated with the entity in a designated format; applying a weight to each of the plurality of data display elements based upon historical levels of user interaction with each of the plurality of data display elements displayed within historical lead summary reports; determining whether each of the weighted plurality of data display elements is at or above at least one threshold; combining the obtained pre-defined subsets to form a subset of a plurality of data display elements, wherein each data display element in the subset satisfies the at least one threshold; automatically obtaining, from a data repository, specific health care claims data associated with the entity for each of the plurality of data display elements in the subset; generating a lead summary report associated with the entity using a report template, the subset, and the obtained specific health care claims data.

“11. The system of claim 10, further comprising a user interface component, at least partially implemented by computing hardware, comprising one or more sequences of instructions which when executed by one or more processors are programmed to automatically provide the lead summary report to facilitate assessment of the suspected fraud by a user.

“12. The system of claim 10, wherein the plurality of data display elements comprise widgets, the report template comprises a web page template, and each of the one or more sources comprises a programmed fraud detection model or scheme.

“13. The system of claim 10, wherein the user interface component is programmed to receive an input comprising an identifier of the entity suspected of fraud.

“14. The system of claim 10, wherein the report generator component is programmed to determine which one or more sources by determining a particular source from among a plurality of sources, and wherein the subset comprises a subset pre-defined for the particular source.

“15. The system of claim 10, wherein the subset comprises a combination of a subset pre-defined for each of the two or more sources.

“16. The system of claim 10, wherein the report generator component is programmed to automatically update the lead summary report in response to detecting a change in the specific health care claims data.

“17. The system of claim 10, further comprising sequences of instructions which are programmed, when executed by the one or more processors, to cause: receiving input from a client computing device specifying a change to the lead summary report; responsive to the input, updating the lead summary report with the change.

“18. The system of claim 10, further comprising sequences of instructions which are programmed, when executed by the one or more processors, to cause creating and digitally storing one or more evidentiary documents based on the lead summary report, in response to an input from a client computing device specifying to preserve the lead summary report at a certain point in time.

“19. The system of claim 10, wherein each of the one or more sources comprises a programmed fraud detection model or scheme.

“20. The system of claim 10, further comprising sequences of instructions which are programmed, when executed by the one or more processors, to cause determining that a source is unknown and that the suspected fraud was identified by a third party computer system, and wherein the subset comprises a particular subset that is pre-defined for use when the source is unknown.

“21. The system of claim 10, further comprising sequences of instructions which are programmed, when executed by the one or more processors, to cause determining a particular source from among a plurality of sources, and wherein the subset comprises a particular subset that is pre-defined for the particular source.

“22. The system of claim 10, wherein the subset comprises a combination of a particular subset that is pre-defined for each of the two or more sources.

“23. The method of claim 1, wherein the combining the obtained pre-defined subsets to form the subset of the plurality of data display elements comprises: determining that a first data display element from a first of the pre-defined subsets is equivalent to a second data display element from a second of the pre-defined subsets; including the first data display element in the subset of the plurality of data display elements; excluding the second data display element from the subset of the plurality of data display elements.

“24. The method of claim 1 wherein the applying the weight to the each of the data display elements included in the each of the pre-defined subsets is in response to determining that a total number of the data display elements in the pre-defined subsets exceeds a limit to a number of data display elements to be included on the lead summary report, and wherein the determining whether the each of the weighed plurality of data display elements is at or above the at least one threshold comprises determining whether each of the weighed plurality of data display elements is most relevant for accessing the entity.

“25. The method of claim 1, wherein the lead summary report comprising an overview page containing hyperlinks to specific display elements of the subset and information about sources of the two or more sources.

“26. The system of claim 10, wherein the lead summary report comprising an overview page containing hyperlinks to specific display elements of the subset and information about sources of the two or more sources.”

For more information, see this patent: Subramanian, Gokul; Agarwal, Rahul; Seaton, William; Wu, Diane. Medical Claims Lead Summary Report Generation. U.S. Patent Number 10,372,879, filed December 21, 2015, and published online on August 19, 2019. Patent URL: http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=10,372,879.PN.&OS=PN/10,372,879RS=PN/10,372,879

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