Automated Insurance Claim Auditing via OCR and Rule Matching
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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 only a minority of claims being manually reviewed for quality and accuracy.
Innovation Solution
A computerized auditing method that translates word strings from claim documents into translated item descriptions, compares them to predetermined 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
1Reliability
If manual review of claim documents is performed, then quality and accuracy of claim settlement can be maintained, but review time and costs increase significantly
Solution Approach 1:
The patent replaces the mechanical manual review process 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 to automatically evaluate claim items against policy guidelines, eliminating the need for manual inspection while maintaining audit quality
Solution Approach 2:
The system enables self-service auditing where the electronic auditing tool automatically performs quality checks, compliance verification, and accuracy validation of claim documents without requiring human auditor intervention for routine evaluations, allowing the system to audit itself against predefined criteria
2Reliability
If all claims are reviewed for quality and accuracy, then cost control and repair quality improve, but the complexity and cost of the review process become prohibitive
Solution Approach 1:
The patent transforms the review process from a complex manual evaluation into a simplified automated system by changing the state of claim documents from imaged format to machine-readable text through OCR, then applying parameter-based rule engines that automatically evaluate claims against predefined criteria, reducing process complexity while enabling comprehensive review of all claims
Solution Approach 2:
The electronic auditing tool serves as an intermediary between claim documents and human auditors, automatically performing initial quality checks, compliance verification, and accuracy validation, thereby simplifying the overall review process while enabling comprehensive evaluation of all claims without prohibitive complexity
3Reliability
If imaged claim documents are used, then document security and authenticity are maintained, but automation of the review process becomes technically impossible
Solution Approach 1:
The patent replaces the physical imaged document system with an electronic text-based system using OCR technology to convert imaged documents into machine-readable format, enabling automated processing while maintaining document integrity through cryptographic verification and audit trails
Solution Approach 2:
The OCR conversion process acts as an intermediary between imaged documents and automated review systems, transforming visual document data into structured text that can be processed electronically while preserving the original document's authenticity through verification mechanisms
4Productivity
If electronic auditing tools are used to flag issues, then preliminary identification of problems is improved, but complete automation of the audit process cannot be achieved
Solution Approach 1:
The patent advances the auditing process from issue-flagging to complete automation by changing the evaluation parameters from requiring human interpretation to using machine-readable text with definitive rule-based criteria that enable automated acceptance or rejection of claim items
Solution Approach 2:
The electronic auditing tool performs self-service automation by automatically evaluating claim items against predefined rules, making automated decisions on claim acceptance or rejection without requiring human auditor intervention, thereby achieving complete audit automation
Data Source
AI summary
Described are computer-based methods and apparatuses, including computer program products, for automation of auditing claims. Data indicative of a vehicle make and model is received, the data comprising one or more make fields and one or more model fields. The one or more model fields are prepared for translation. The one or more make fields are prepared for translation by applying one or more rules from the plurality of rules. Each field of the one or more make fields is associated with one or more make model entries from a plurality of predetermined make model entries. Each field of the one or more model fields is associated with one or more make model entries from the plurality of predetermined make model entries. The data is automatically translated into one or more vehicle identifiers based on the associated make model entries.