Dynamic Pivot Analysis for Insurance Fraud Detection
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Solution Overview
Problem
Conventional link analysis software is ineffective in analyzing large quantities of data related to questionable payment requests from organized groups of service providers, such as medical providers, which often change locations and business identities before investigations can be conducted.
Innovation Solution
A computer system that aggregates and analyzes insurance claims and payment request data using a pivot analysis table to expose links among service providers, allowing for rapid identification of questionable payment requests and enabling insurance companies to prevent or defer payments.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If conventional link analysis software is used to analyze payment request data, then analysis capability is provided, but the software cannot provide useful output when analyzing large quantities of data
Solution Approach 1:
The patent segments the analysis process into multiple specialized modules: data ingestion module for collecting payment requests, data normalization module for standardizing formats, link analysis module for identifying relationships, and reporting module for generating outputs. This segmentation allows each module to optimize for its specific function, enabling the system to handle large datasets effectively while maintaining output quality.
Solution Approach 2:
The system implements dynamic configuration capabilities where analysis parameters, data sources, and processing rules can be adjusted based on the specific dataset being analyzed. The link analysis algorithms dynamically adapt to the volume and characteristics of incoming data, allowing the system to maintain useful output quality across varying data quantities rather than being static in its approach.
2Measurement precision
If investigation units manually analyze payment requests from organized groups of service providers, then detailed investigation can be conducted, but the providers can change locations and business identities before investigations are completed
Solution Approach 1:
The system performs preliminary automated analysis of payment request data, identifying potential links and suspicious patterns before human investigators begin their work. This preliminary action pre-processes large volumes of data, flagsging high-risk cases and organizing information in advance, so that when investigators do review cases, the most critical information is already prepared and linked relationships are pre-identified, reducing the time needed for thorough investigation.
Solution Approach 2:
The patent replaces manual mechanical investigation processes with automated computational analysis. Computer algorithms continuously scan and analyze payment request data, automatically identifying links between service providers and detecting suspicious patterns 24/7 without human intervention. This substitution of mechanical human analysis with automated systems enables both thoroughness and speed, as the system can process vast amounts of data instantly while maintaining detailed investigative capabilities.
Data Source
AI summary
A computer system includes a data storage module. The data storage module receives, stores, and provides access to data related to payment requests submitted to an insurance company by service providers. The data storage module is coupled to a computer processor. Also coupled to the computer processor are a program memory, an input device and an output device. The input device is used to input information to identify a first service provider. The display device is used to display data about other service providers who are associated with the same insurance claims as the first service provider. The data displayed about the other service providers includes taxpayer identification numbers (TINs).