Automated Insurance Claim Auditing via Text Translation
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Solution Overview
Problem
Current systems lack the capability to automate the review, approval, and payment process for insurance claims due to the inability to convert imaged claim documents into a usable electronic form, leading to inefficiencies and inflated costs, with manual audits being time-consuming and limited in scope.
Innovation Solution
A computerized auditing method that translates word strings from claim documents into translated item descriptions, compares them to predefined terms, and associates them with item identifiers based on matching information, allowing for automated acceptance or rejection of claim items according to predefined rules.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If manual auditing methods are used to review claim documents, then auditing accuracy can be maintained through human judgment, but review time and costs are excessive and only a minority of claims can be reviewed
Solution Approach 1:
The patent replaces manual mechanical auditing processes with an automated electronic auditing system that uses optical character recognition (OCR) to convert imaged documents into machine-readable text, then applies rule-based algorithms and artificial intelligence to analyze claim items. This substitution enables full automation of the auditing process, allowing 100% of claims to be reviewed electronically rather than relying on limited manual review capacity.
Solution Approach 2:
The auditing system performs self-service by automatically translating word strings from claim documents into structured data, comparing them against predefined terms and rules, and generating audit results without continuous human intervention. The system autonomously processes claims through multiple translation steps, applies business rules, and produces standardized outputs, reducing dependency on manual auditor labor while maintaining consistent auditing standards across all claims.
2Reliability
If imaged claim documents are used for review, then document authenticity and completeness are preserved, but automation of the review process becomes technically impossible
Solution Approach 1:
The patent introduces optical character recognition (OCR) technology as an intermediary between imaged claim documents and the electronic auditing system. The OCR process converts visual text from images into machine-readable characters, creating a bridge that allows automated systems to process and analyze claim information while preserving the original imaged documents for reference and verification.
Solution Approach 2:
The system changes the parameter of document representation from static images to dynamic, machine-readable text data through multiple translation steps. By converting imaged documents into structured electronic formats with standardized fields and data types, the system enables automated processing while maintaining the ability to trace back to original document sources for quality control and dispute resolution.
3Productivity
If electronic auditing tools are used with predefined codes, then processing speed increases, but the tools can only flag issues rather than complete audits and rely on codes that may not exist for all line items
Solution Approach 1:
The patent applies preliminary action by pre-translating and standardizing claim document data into structured formats with predefined codes and categories before the auditing process begins. The system performs initial translation of word strings into standardized item descriptions and associates them with relevant codes during document ingestion, so that when auditing rules are applied, the data is already prepared for efficient electronic processing while maintaining adaptability to various claim types.
Solution Approach 2:
The auditing system incorporates dynamics by allowing flexible translation and code association during the auditing process itself. Rather than requiring all data to be pre-coded, the system can dynamically translate and match items against predefined terms and rules during processing, adapting to non-coded or manually modified line items while maintaining consistent auditing standards through rule-based evaluation.
Data Source
AI summary
Described are computer-based methods and apparatuses, including computer program products, for automation of auditing claims. A data file is received comprising one or more auditable items, each auditable item comprising a word string having one or more words. Each word string for each auditable item is translated using one or more translation steps into a translated item description. Each translated item description is compared to a plurality of terms to generate matching information. Each translated item description is associated with an item identifier based on the matching information. Each auditable item is accepted or rejected based on the item identifier and one or more rules associated with the data file.