System for dynamic fraud detection

Patent metadata

Field	Value
Publication number	US-2016110818-A1
Application number	US-201514697051-A
Country	US
Kind code	A1
Filing date	Apr 27, 2015
Priority date	Oct 21, 2014
Publication date	Apr 21, 2016
Grant date	—

Abstract

According to some embodiments, data is received indicative of a plurality of insurance claims. It may then be automatically determined that a first insurance claim is associated with a first type of insurance and that a second insurance claim is associated with a second type of insurance different from the first type of insurance. The received data associated with the first insurance claim may be analyzed, in accordance with first fraud detection logic, to determine a first questionable loss status appropriate for the first insurance claim. Similarly, the received data associated with the second insurance claim may be analyzed, in accordance with second fraud detection logic different from the first fraud detection logic, to determine a second questionable loss status appropriate for the second insurance claim. Indications of the first and second questionable loss statuses may then be transmitted (e.g., to a claim handler or a special investigation unit platform).

First claim

What is claimed is:

1 . A system having a data sharing architecture for a network of computers to perform insurance fraud detection, comprising:
a communication device to receive data indicative of a plurality of insurance claims submitted in connection with insurance policies; a computer storage unit for receiving, storing, and providing said data indicative of the plurality of insurance claims; and a fraud detection platform processor in communication with the storage unit, wherein the processor is configured for:
automatically determining that a first insurance claim is associated with a first type of insurance and that a second insurance claim is associated with a second type of insurance different from the first type of insurance,
analyzing the received data associated with the first insurance claim, in accordance with first fraud detection logic, to calculate an indicator strength score for the first insurance claim,
based on the indicator strength score for the first insurance claim, determining a first questionable loss status appropriate for the first insurance claim, wherein the first questionable loss status comprises one of: (i) an unlikely questionable loss that is not automatically referred to a special investigation unit platform, (ii) a likely questionable loss that is automatically referred to the special investigation unit platform, and (iii) a potential questionable loss that is flagged for further review by a claim handler,
analyzing the received data associated with the second insurance claim, in accordance with second fraud detection logic different from the first fraud detection logic, to determine a second questionable loss status appropriate for the second insurance claim, and
transmitting indications of the first and second questionable loss statuses.

2 . The system of claim 1 , wherein the processor is further for:
receiving updated information about the first insurance claim, analyzing the updated data associated with the first insurance claim, in accordance with first fraud detection logic, to calculate an updated indicator strength score for the first insurance claim, based on the updated indicator strength score for the first insurance claim, determining an updated questionable loss status appropriate for the first insurance claim.

3 . The system of claim 1 , wherein analyzing the received data associated with the first insurance claim, in accordance with the first fraud detection logic, is further associated with a fraud detection wizard completed by a claim handler.

4 . The system of claim 3 , wherein the processor is further configured for:
displaying the indicator strength score to the claim handler via a graphical user interface display.

5 . The system of claim 4 , wherein said calculating comprises summing a series of indicators relevant to the first insurance claim, each relevant indicator being multiplied by an indicator weight.

6 . The system of claim 1 , wherein the processor is further configured for:
automatically generating claim notes to be forwarded to a special investigation unit platform.

7 . The system of claim 1 , wherein the processor is further configured for:
displaying, to a claim handler, an investigation checklist including a plurality of investigation tasks, and receiving, from the claim handler, a status for each investigation task, wherein at least one status comprises an inquiry to a special investigation unit platform.

8 . The system of claim 1 , wherein at least one of the first and second types of insurance are associated with at least one of: (i) workers' compensation insurance, (ii) automobile insurance, (iii) homeowners insurance, (iv) property insurance, (v) general liability insurance, (vi) commercial insurance, and (vii) personal insurance.

9 . The system of claim 1 , wherein at least one of the first and second fraud detection logic is associated with at least one of: (i) an indication an insured reported claim as questionable, (ii) an insurance period start date, (iii) an insurance period end date, (iv) an employment start date, and (v) an employment end date, (vi) prior insurance claims, (vii) disciplinary action information, (viii) a lack of a witness, (ix) claimant attorney information, and (x) a medical bill date.

10 . The system of claim 1 , wherein at least one of the first and second fraud detection logic is associated with at least one of: (i) vehicle damage information, (ii) a vehicle repair location, (iii) an arson indication, (iv) an accident type, and (v) a time of accident.

11 . The system of claim 1 , wherein the received data indicative of a plurality of insurance claims are associated with first notices of loss.

12 . The system of claim 1 , wherein the received data indicative of a plurality of insurance claims include at least three of: (i) a date and time, (ii) a claim number, (iii) a claim type, (iv) a loss date, (v) a benefit state, (vi) a claimant name, (vii) a claimant date of birth, (viii) a cause of injury, (ix) a claim description, (x) a body part, (xi) an injury, (xii) a return to work date, (xiii) an indication of whether the claimant was injured doing normal job duties, (xiv) an employment status, (xv) an indication of whether an injury resulted in death, (xvi) an indication of whether the injury requires surgery, (xvii) an indication of whether claim involves equipment or machinery, (xviii) an indication of whether safety equipment was provided, (xix) an indication of whether the claim is questionable, and (xx) an indication of whether and injured worker is represented by an attorney.

13 . The system of claim 1 , wherein the processor is further configured for:
automatically transmitting indications of the first and second questionable loss status to at least one of: (i) an email server, (ii) a workflow application, (iii) a report generator, (iv) a calendar application, (v) a claim handler system, and (v) a special investigation unit platform.

14 . The system of claim 1 , wherein the data indicative of the plurality of insurance claims is received via at least one of: (i) submitted paper claims, (ii) telephone call center operators, and (iii) an online claim submission web site.

15 . The system of claim 1 , wherein at least one of the first and second fraud detection logic is associated with a predictive model trained with historical insurance claim information.

16 . The system of claim 15 , wherein the predictive model is associated with at least one of: (i) a neural network, (ii) a Bayesian network, (iii) a Hidden Markov model, (iv) an expert system, (v) a decision tree, (vii) a collection of decision trees, (viii) a support vector machine, and (ix) weighted factors.

17 . A method to administer a data sharing architecture for a network of computers to perform insurance fraud detection for an insurance claim processing system, comprising:
receiving, by a communication device, data indicative of a plurality of insurance claims submitted in connection with insurance policies; storing, by a computer storage unit, said data indicative of the plurality of insurance claims; automatically determining, by a fraud detection platform processor, that a first insurance claim is associated with a first type of insurance and that a second insurance claim is associated with a second type of insurance different from the first type of insurance, analyzing the received data associated with the first insurance claim, by the fraud detection platform processor in accordance with first fraud detection logic, to calculate an indicator strength score f

Assignees

• Hartford Fire Insurance Comp

Inventors

• Shemesh Keren
• Edwards Paul J
• Hayden Geoffrey P
• Preece Andrew D
• Waters Ii Odie

Classifications

• G06Q40/08 Primary

  Insurance · CPC title