Patent Issued for Systems And Methods For Predictive Personalization And Intelligent Routing (USPTO 10,594,866)

2020 MAR 30 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- According to news reporting originating from Alexandria, Virginia, by NewsRx journalists, a patent by the inventors Babjack, Destiny (Bethel Park, PA); Howell, Peter D. (St. Paul, MN); Bargman, Eric (St. Louis Park, MN); Groat, Tina (Frisco, TX); Tan, Kevin (Minnetonka, MN); Kelly, Tom (Shorewood, MN); Long, Sandra (St. Paul, MN); McNattin, Sean (Dayton, MN); Kumar, Mayank (Noida, IN); Sundberg, Lawrence Kevin (Big Lake, MN), filed on September 6, 2018, was published online on March 30, 2020.

The assignee for this patent, patent number 10,594,866, 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, NewsRx editors also obtained the inventors’ summary information for this patent: “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:

“What is claimed is:

“1. A secure network for intelligently routing an organization’s member to an organization representative, comprising: an authentication processor configured to authenticate the member using automatic number identification; a natural language processor configured to provide the member with one or more open-ended questions and to analyze spoken content of the member to determine an explicit need of the member based on the spoken content being responsive to one or more open-ended questions; and a conversation management processor configured to: generate an aggregate diagnosis score that indicates members with ambiguous diagnoses; generate a member diagnosis score based on member data associated with the member; classify the member into one of a plurality of specialized diagnosis classifications of the member, the specialized diagnosis classification being based on a comparison of the member score to the aggregate diagnosis score and indicating an ambiguous diagnosis for the member; determine any special needs of the member based on the specialized diagnosis classification of the member and the ambiguous diagnosis; and determine a representative to route the member to, based in part on the specialized diagnosis classification, the special needs, and the explicit need of the member, the representative being capable of addressing the needs of the member.

“2. The secure network of claim 1 wherein the aggregate score is based on traits historically identifying members with ambiguous diagnoses.

“3. The secure network of claim 1 wherein the member score is based on household data.

“4. The secure network of claim 1 wherein the specialized diagnosis classification of the member comprises a special needs classification.

“5. The secure network of claim 1 wherein the comparison of the member score to the aggregate score comprises determining if the member score is outside of three standard deviations of the aggregate score.

“6. A method for intelligently routing a member of an organization to an organization representative, comprising: providing at least one open-ended question to the member; receiving a communication from the member, the communication including spoken words; determining an identity of the member; determining an aggregate member score that indicates members with ambiguous diagnoses; determining a member score based on member data from the member; classify the member into one of a plurality of specialized diagnosis classifications associated with any special needs of the member using a comparison of the member score to the aggregate score, the specialized diagnosis classification indicating an ambiguous diagnosis for the member; determining any special needs of the member based on the specialized diagnosis classification of the member and the ambiguous diagnosis; and determining an organization representative to route the member to based in part on the determined specialized diagnosis classification, the special needs, and the explicit need of the member, the representative being capable of addressing the needs of the member.

“7. The method of claim 6, wherein the diagnosis classification is further determined by analyzing spoken content of the member.

“8. A system for establishing communication between an organization’s member and an organization representative, comprising: an authentication processor configured to authenticate the member using automatic number identification; a natural language processor configured to provide the member with at least one open-ended question and to analyze spoken content of the member to determine an explicit need of the member, the spoken content being responsive to the at least one open-ended question; a conversation management processor configured to: generate a member alert score for the member; compare the member alert score to an aggregate data set for all members from the organization, the aggregate data set indicating members with ambiguous diagnoses; classify the member into one of a plurality of alert tiers based on the comparison of the member alert score and the aggregate data set, the alert tier used to determine an ambiguous diagnosis classification indicating an ambiguous diagnosis for the member; determine any special needs of the member based on the ambiguous diagnosis classification of the member; and define at least one conversation action based on the determined alert tier, the ambiguous diagnosis classification, the special needs, and the explicit need of the member.

“9. The system of claim 8 wherein the alert tier is a classification selected from the group consisting of: High, Medium and Low.

“10. The system of claim 8 wherein the conversation action comprises one of an email, a short message service message, a multimedia message service message, a phone call, a chat session, or graphical user interface display.

“11. The system of claim 8 wherein the conversation action is executed automatically upon being defined.

“12. The system of claim 8 wherein the member alert score comprises an emotional impact score, a financial impact score and a claim fixability score.

“13. The system of claim 8 wherein the organization’s member is routed to the organization representative using routing rules.

“14. The system of claim 13 wherein the routing rules are applied to the organization’s member household level data to determine routing to the organization representative using the routing rules.

“15. The system of claim 14 wherein the household level data is aggregated to compare to a routing threshold to determine routing to the organization representative using the routing rules.

“16. The system of claim 13 wherein the routing rules are used to determine if the organization’s member is routed to a Tier 1, Tier 2 or Tier 3 organization representative and if a Tier 3 routing threshold is not surpassed the organization’s member is routed a Tier 2 organization representative.

“17. The system of claim 13 wherein the routing rules are used to route the organization’s member to an organization representative in a Tier using default routing.

“18. The system of claim 13 wherein a quality check on appropriateness of selected intelligent routing rules is implemented for intelligent routing of the organization’s member to the organization representative.”

For more information, see this patent: Babjack, Destiny; Howell, Peter D.; Bargman, Eric; Groat, Tina; Tan, Kevin; Kelly, Tom; Long, Sandra; McNattin, Sean; Kumar, Mayank; Sundberg, Lawrence Kevin. Systems And Methods For Predictive Personalization And Intelligent Routing. U.S. Patent Number 10,594,866, filed September 6, 2018, and published online on March 30, 2020. 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=10,594,866.PN.&OS=PN/10,594,866RS=PN/10,594,866

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