AI Claims Processing Alert System
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Solution Overview
Problem
Existing automated claims processing systems lack the ability to efficiently identify potential issues with claims, such as fraud, in a timely manner.
Innovation Solution
A method and system utilizing an AI model to analyze claim characteristics and determine alert reasons based on similarities with other claims, generating alert notifications for potential issues.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If traditional automated claims processing systems are used, then processing speed is maintained, but the ability to identify potential issues with claims is insufficient
Solution Approach 1:
The patent introduces an AI model as an intermediary component between the traditional claims processing system and the issue identification function. The AI model receives claim data and characteristics from the existing system and outputs alert reasons for potential issues, thereby enhancing reliability without requiring complete system redesign
Solution Approach 2:
The patent segments the issue identification function into a separate AI-based module that operates independently from the core claims processing system. By identifying and extracting specific claim characteristics as separate inputs to the AI model, the system adds issue detection capability while maintaining the original processing workflow intact
2Measurement precision
If AI model analysis is implemented to identify claim issues, then detection accuracy improves, but processing time increases
Solution Approach 1:
The patent performs preliminary action by pre-identifying and extracting key claim characteristics before submitting them to the AI model for analysis. This preparation step organizes data in advance, enabling the AI model to process claims more efficiently and reduce overall processing time while maintaining high detection accuracy
Solution Approach 2:
The patent extracts only the most relevant claim characteristics needed for issue detection rather than analyzing the entire claim document. By taking out and focusing on specific key features, the system reduces the computational burden on the AI model and accelerates processing while preserving detection precision
Data Source
AI summary
In some embodiments, a processor may receive a claim, where the claim relates to an event. The processor may identify characteristics of the claim. The processor may determine, using an AI model, an alert reason based on a similarity of the characteristics of the claim to characteristics of one or more other claims. The processor may generate an alert notification, and the processor may output the alert notification to a user.