“System And Method For Auditing Insurance Claims” in Patent Application Approval Process (USPTO 20190279306)

2019 OCT 02 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- A patent application by the inventors Wassel, Mark (Geneva, IL); Muthukumaraswamy, Shankar (Chennai, IN); Saraf, Aditi (San Francisco, CA), filed on May 9, 2018, was made available online on September 12, 2019, according to news reporting originating from Washington, D.C., by NewsRx correspondents.

This patent application is assigned to Cognizant Technology Solutions India Pvt. Ltd. (Chennai, India).

The following quote was obtained by the news editors from the background information supplied by the inventors: “Claims leakage is the money lost through claims management inefficiencies resulting from errors and missed steps by claim adjusters. The insurance industry estimates claims leakage to approximately seven percent of the claims paid. Insurance companies endeavor to minimize claims leakage to reduce costs and increase profits.

“Conventionally, claims leakage is managed through closed file reviews. Closed file reviews are manual and detailed audits conducted on small samples of adjusters’ files to identify source of leakage and leverage the findings to coach and mentor adjusters. Closed file reviews promote appropriate conduct and investigations by adjusters in future claim settlements. However, since reviews are conducted on closed files there is no opportunity to correct the outcome of the claim prior to settlement. To overcome the above-mentioned drawbacks, insurance companies desire managers to conduct reviews on active claim files. However, managers have numerous claim adjusters under them and claim adjusters have hundreds of active claim files allocated at a time thus reducing the number of active file reviews. This results in limited opportunities to scrutinize performance of the adjuster and identifying areas of strengths and weaknesses. Moreover, as reviews are manual, it becomes difficult to analyze the results of the review, track performance of the adjusters against key attributes across all assigned files and simplify the identification of trends and opportunities for improvements. In order to overcome the limitations of manual file reviews, insurance companies use existing claims administration systems. However, the existing claims administration systems also suffer from several disadvantages. The existing claims administration systems provide only one-off audits of certain activities in a claim lifecycle. The existing claims administration systems do not provide comprehensive auditing throughout the lifecycle of all active claims and across various performance and outcome attributes. Also, the existing claims administration systems do not direct managers to problematic claim files in their portfolio and therefore do not provide any opportunity for correcting the outcome of the claim prior to settlement.

“In light of the above-mentioned disadvantages, there is a need for a system and method for auditing insurance claims prior to claim settlement. There is a need for a system and method that allows comprehensive and systemic audit of all active claim files. Further, there is a need for a multi-variant claims data analytics system for auditing active claims across multiple performance and outcome attributes, flagging problematic claims and advising managers of the issues occurring on the file thereby providing opportunity for course correction prior to settlement. Furthermore, there is a need for a system and method that is capable of tracking performance of claim adjusters against key performance attributes on all assigned files and providing insight into adjusters’ strengths and opportunities for improvement.”

In addition to the background information obtained for this patent application, NewsRx journalists also obtained the inventors’ summary information for this patent application: “A system, computer-implemented method and computer program product for auditing insurance claims is provided. The system comprises a source data extractor configured to extract one or more claim records from one or more sources. The system further comprises a transformation engine configured to transform the one or more received claim records to a data model, wherein the data model comprise information present in the one or more received claim records in a pre-defined and structured format and load the data model to a claims audit database. Furthermore, the system comprises a segmentation engine configured to interrogate the claims audit database and categorize each claim record within the loaded data model into one or more pre-defined categories. The system also comprises a claims audit engine configured to execute one or more predefined audit rules corresponding to each of the one or more categories for auditing each of the one or more claim records and generate at least one of: audit information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed audit rules.

“In an embodiment of the present invention, the one or more sources comprise claim administration systems employed by one or more insurance carriers, document repositories, media repositories and third party sources. In an embodiment of the present invention, the one or more pre-defined categories are configured by one or more insurance carriers based on type of insurance, complexity of claim and type of loss. In an embodiment of the present invention, the one or more predefined audit rules are executed based on category and stage of each of the one or more claim records. In an embodiment of the present invention, the claims audit engine executes the one or more predefined audit rules corresponding to one or more audit events and further wherein the one or more audit events comprise activity audit, document audit, progress audit, engagement audit, vendor management audit and inconsistency audit.

“In an embodiment of the present invention, the generated audit information comprise information related to one or more audit events conducted at specific stages of the claim, results of each audit event, results of the execution of the one or more predefined audit rules and status of the one or more claim records. In an embodiment of the present invention, the one or more alerts comprise summary of the results of the audit conducted by the claims audit engine for each of the one or more claim records. In an embodiment of the present invention, the one or more alerts corresponding to each of the one or more claim records are forwarded via one or more communication channels. Further, the one or more communication channels comprise electronic mails, short messaging service, facsimile and instant messengers. In an embodiment of the present invention, the system further comprises a user interface manager configured to provide at least one: of the generated audit information and the one or more alerts in the form of summarized dashboards and detailed insights.

“The computer-implemented method for auditing insurance claims, via program instructions stored in a memory and executed by a processor comprises extracting one or more claim records from one or more sources. The computer-implemented method further comprises transforming the one or more received claim records to a data model, wherein the data model comprise information present in the one or more received claim records in a pre-defined and structured format. Furthermore, the computer-implemented method comprises loading the data model to a claims audit database, interrogating the claims audit database and categorizing each claim record within the loaded data model into one or more pre-defined categories. Also, the computer-implemented method comprises executing one or more predefined audit rules corresponding to each of the one or more pre-defined categories for auditing each of the one or more claim records. The computer-implemented method further comprises generating at least one of: audit information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed audit rules.

“The computer program product for auditing insurance claims 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 extract one or more claim records from one or more sources. The processor further transforms the one or more received claim records to a data model, wherein the data model comprise information present in the one or more received claim records in a pre-defined and structured format. Furthermore, the processor loads the data model to a claims audit database, interrogates the claims audit database and categorizes each claim record within the loaded data model into one or more pre-defined categories. The processor also executes one or more predefined audit rules corresponding to each of the one or more pre-defined categories for auditing each of the one or more claim records. The processor further generates at least one of: audit information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed audit rules.”

The claims supplied by the inventors are:

“1. A system for auditing insurance claims, the system comprising: a source data extractor configured to extract one or more claim records from one or more sources; a transformation engine configured to: transform the one or more received claim records to a data model, wherein the data model comprise information present in the one or more received claim records in a pre-defined and structured format; and load the data model to a claims audit database; a segmentation engine configured to interrogate the claims audit database and categorize each claim record within the loaded data model into one or more pre-defined categories; and a claims audit engine configured to: execute one or more pre-defined audit rules corresponding to each of the one or more categories for auditing each of the one or more claim records; and generate at least one of: audit information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed audit rules.

“2. The system of claim 1, wherein the one or more sources comprise claim administration systems employed by one or more insurance carriers, document repositories, media repositories and third party sources.

“3. The system of claim 1, wherein the one or more pre-defined categories are configured by one or more insurance carriers based on type of insurance, complexity of claim and type of loss.

“4. The system of claim 1, wherein the one or more audit rules are executed based on category and stage of each of the one or more claim records.

“5. The system of claim 1, wherein the claims audit engine executes the one or more audit rules corresponding to one or more audit events and further wherein the one or more audit events comprise activity audit, document audit, progress audit, engagement audit, vendor management audit and inconsistency audit.

“6. The system of claim 1, wherein the generated audit information comprise information related to one or more audit events conducted at specific stages of the claim, results of each audit event, results of the execution of the one or more audit rules and status of the one or more claim records.

“7. The system of claim 1, wherein the one or more alerts comprise summary of the results of the audit conducted by the claims audit engine for each of the one or more claim records.

“8. The system of claim 1, wherein the one or more alerts corresponding to each of the one or more claim records are forwarded via one or more communication channels.

“9. The system of claim 8, wherein the one or more communication channels comprise electronic mails, short messaging service, facsimile and instant messengers.

“10. The system of claim 1 further comprising a user interface manager configured to provide at least one: of the generated audit information and the one or more alerts in the form of summarized dashboards and detailed insights.

“11. A computer-implemented method for auditing insurance claims, via program instructions stored in a memory and executed by a processor, the computer-implemented method comprise: extracting one or more claim records from one or more sources; transforming the one or more received claim records to a data model, wherein the data model comprise information present in the one or more received claim records in a pre-defined and structured format; loading the data model to a claims audit database; interrogating the claims audit database and categorizing each claim record within the loaded data model into one or more pre-defined categories; executing one or more pre-defined audit rules corresponding to each of the one or more pre-defined categories for auditing each of the one or more claim records; and generating at least one of: audit information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed audit rules.

“12. The computer-implemented method of claim 11, wherein the one or more sources comprise claim administration systems employed by one or more insurance carriers, document repositories, media repositories and third party sources.

“13. The computer-implemented method of claim 11, wherein the one or more pre-defined categories are configured by one or more insurance carriers based on type of insurance, complexity of claim and type of loss.

“14. The computer-implemented method of claim 11, wherein the one or more audit rules are executed based on category and stage of each of the one or more claim records.

“15. The computer-implemented method of claim 11, wherein the one or more audit rules are executed corresponding to one or more audit events and further wherein the one or more audit events comprise activity audit, document audit, progress audit, engagement audit, vendor management audit and inconsistency audit.

“16. The computer-implemented method of claim 11, wherein the audit information comprise information related to one or more audit events conducted at specific stages of the claim, results of each audit event, results of the execution of the one or more audit rules and status of the one or more claim records.

“17. The computer-implemented method of claim 11, wherein the one or more alerts comprise summary of the results of the audit for each of the one or more claim records.

“18. The computer-implemented method of claim 11, wherein the one or more alerts corresponding to each of the one or more claim records are forwarded via one or more communication channels.

“19. The computer-implemented method of claim 18, wherein the one or more communication channels comprise electronic mails, short messaging service (SMS), facsimile and instant messengers.

“20. The computer-implemented method of claim 11 further comprising providing at least one: of the generated audit information and the one or more generated alerts in the form of summarized dashboards and detailed insights.

“21. A computer program product for auditing insurance claims, the 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: extract one or more claim records from one or more sources; transform the one or more received claim records to a data model, wherein the data model comprise information present in the one or more received claim records in a pre-defined and structured format; load the data model to a claims audit database; interrogate the claims audit database and categorizing each claim record within the loaded data model into one or more pre-defined categories; execute one or more audit rules corresponding to each of the one or more pre-defined categories for auditing each of the one or more claim records; and generate at least one of: audit information and one or more alerts corresponding to each of the one or more claim records based on results of the one or more executed audit rules.”

URL and more information on this patent application, see: Wassel, Mark; Muthukumaraswamy, Shankar; Saraf, Aditi. System And Method For Auditing Insurance Claims. Filed May 9, 2018 and posted September 12, 2019. 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=%2220190279306%22.PGNR.&OS=DN/20190279306&RS=DN/20190279306

(Our reports deliver fact-based news of research and discoveries from around the world.)