Computer System for Medical Triage Determinations and Related System Interactions

Abstract

According to some embodiments, historical claim data may be stored in a computer storage unit. The historical claim data may be used to train and verify a predictive model, the predictive model being associated with an evaluation of transactions to determine whether to refer each transaction to an intervention program. Data for current transactions may be processed, and the trained and verified predictive model may be applied to the data for the current transactions to generate a respective output for each of the current transactions. Some of the current transactions may be selectively routed to a management computer associated with the intervention program based on the outputs generated by the predictive model.

What is claimed is: 
     
         1 . A computer system for data processing including triage benefit determination and triage recommendation determination using a computerized predictive model, comprising:
 a triage program computer, comprising:
 a data storage device storing data indicative of a trained computerized predictive model, trained based on historical claim transaction data, configured to determine, based on insurance claim transaction data, a nurse intervention program indication indicative of a triage recommendation; 
 one or more computer processors in communication with the data storage device; and 
 a program memory, coupled to the one or more computer processors, storing program instructions for execution by the one or more computer processors, the program instructions, when executed by the one or more computer processors, causing the one or more computer processors to:
 receive a current claim transaction file for a case including available information corresponding to the case; 
 determine whether an account corresponding to the current claim transaction file includes a triage benefit; 
 responsive to a determination that the account does not include a triage benefit, end processing relating to the current claim transaction file; 
 responsive to a determination that the account includes a triage benefit:
 create a triage activity; 
 input the available information to the predictive model, 
 
 wherein the predictive model is responsive to one or both of data indicative of a predicted ultimate medical claim severity and data indicative of a predicted ultimate indemnity claim severity;
 receive as an output from the predictive model an indication as to whether triage is recommended for the current claim transaction file; 
 responsive to a negative indication that triage is recommended, end processing of the current claim transaction file; 
 responsive to a positive indication that triage is recommended, transmit the current claim transaction file to a case management computer; and 
 
 
   the case management computer in communication with the triage computer system and configured to receive the data relating to the current claim transaction responsive to the positive indication that triage is recommended.   
     
     
         2 . The computer system of  claim 1 , wherein determining whether the account corresponding to the current claim transaction file includes the triage benefit is based on special account instructions associated with the account. 
     
     
         3 . The computer system of  claim 1 , wherein the triage activity is associated with an insurance processing workflow system. 
     
     
         4 . The computer system of  claim 1 , wherein the predictive model is further responsive to values of co-morbidity data comprising at least two of (i) alcohol related co-morbidity information, (ii) drug related co-morbidity information, (iii) tobacco related co-morbidity information, (iv) arthritis related co-morbidity information, (v) diabetes related co-morbidity information, or (vi) obesity related co-morbidity information; and    
     
     
         5 . The computer system of  claim 1 , wherein the predictive model is further responsive to data indicative of each of demographic information, injury details, accident information, employment information, and financial information. 
     
     
         6 . The computer system of  claim 1 , wherein the predictive model is further responsive to data indicative of Part Of Body (POB) injured and a Nature Of Injury (NOI). 
     
     
         7 . The computer system of  claim 1 , wherein the predictive model is further responsive to data indicative of a claim complexity, an injury, and an occupation. 
     
     
         8 . The computer system of  claim 1 , wherein said predictive model utilizes an injury matrix for assigning scores to an injury to determine if triage is recommended for the case. 
     
     
         9 . The computer system of  claim 1 , wherein the triage program computer program memory further stores program instructions which cause the one or more computer processors to:
 receive additional information corresponding to the case; and   input the additional information to the predictive model in addition to the available information.   
     
     
         10 . The computer system of  claim 1 , wherein the triage program computer program memory further stores program instructions which cause the one or more computer processors to, responsive to the positive indication that triage is recommended, receive approval for the triage from the account prior to transmitting the current claim transaction file to the case management computer. 
     
     
         11 . A computer-implemented method for managing nurse intervention program decisions including triage benefit determinations and triage recommendations using a computerized predictive model, the method comprising:
 storing, on a data storage device, a trained computerized predictive model, trained based on historical claim transaction data and configured to determine, based on insurance claim transaction data, a nurse intervention program indication indicative of a triage recommendation;   receiving, by a communications device, a current claim transaction file for a case including available information corresponding to the case;   determining, by one or more computer processors, whether an account corresponding to the current claim transaction file includes a triage benefit;   responsive to a determination that the account does not include the triage benefit, ending, by the one or more computer processors, processing relating to the current claim transaction file;   responsive to a determination that the account includes the triage benefit:
 creating, by the one or more computer processors, a triage activity; 
 inputting, by the one or more computer processors, the available information to the predictive model, wherein the predictive model is responsive to one or both of data indicative of a predicted ultimate medical claim severity and data indicative of a predicted ultimate indemnity claim severity; 
 receiving, by the one or more computer processors, an indication as to whether triage is recommended for the current claim transaction file; 
 responsive to a negative indication that triage is recommended, ending, by the one or more computer processors, processing of the current claim transaction file; 
 responsive to a positive indication that triage is recommended, transmitting, by the one or more computer processors, the current claim transaction file to a case management computer. 
   
     
     
         12 . The computer-implemented method of  claim 11 , wherein the predictive model is further responsive to values of co-morbidity data comprising at least two of (i) alcohol related co-morbidity information, (ii) drug related co-morbidity information, (iii) tobacco related co-morbidity information, (iv) arthritis related co-morbidity information, (v) diabetes related co-morbidity information, or (vi) obesity related co-morbidity information; and    
     
     
         13 . The computer-implemented method of  claim 11 , wherein the predictive model is further responsive to data indicative of each of demographic information, injury details, accident information, employment information, financial information, claim complexity, Part Of Body (POB) injured, and a Nature Of Injury (NOI). 
     
     
         14 . The computer-implemented method of  claim 11 , wherein said predictive model assigns scores to an injury based on an injury matrix to determine if triage is recommended for the case. 
     
     
         15 . The computer-implemented method of  claim 11 , further comprising:
 receiving, by the one or more computer processors, additional information corresponding to the case; and   inputting, by the one or more computer processors, the additional information to the predictive model in addition to the available information.   
     
     
         16 . The computer-implemented method of  claim 11 , further comprising, responsive to the positive indication that triage is recommended, receiving approval for the triage from the account prior to transmitting the current claim transaction file to the case management computer. 
     
     
         17 . A computer system for data processing including triage benefit determinations and triage recommendation determinations using a computerized predictive model, comprising:
 a triage program computer, comprising:
 a data storage device storing data indicative of a trained predictive model, trained based on historical claim transaction data, configured to determine, based on insurance claim transaction data, a nurse intervention program indication indicative of whether triage is recommended for providing health care to an injured individual by a nurse; 
 one or more computer processors in communication with the data storage device; and 
 a program memory, coupled to the one or more computer processors, storing program instruction steps for execution by the one or more computer processors, the program instructions, when executed by the one or more computer processors, causing the one or more computer processors to:
 receive a current claim transaction file for a case including available information corresponding to the case; 
 determine whether an account corresponding to the current claim transaction file includes a triage benefit; 
 responsive to a determination that the account does not include the triage benefit, end processing relating to the current claim transaction file; 
 responsive to a determination that the account includes the triage benefit:
 create a triage activity; 
 input the available information to the predictive model, 
 
 wherein the predictive model is responsive to one or both of data indicative of a predicted ultimate medical claim severity and data indicative of a predicted ultimate indemnity claim severity;
 receive an indication as to whether triage is recommended for the current claim transaction file; 
 responsive to a negative indication that triage is recommended, end processing of the current claim transaction file; 
 responsive to a positive indication that triage is recommended, transmit the current claim transaction file to a case management computer. 
 
 
   
     
     
         18 . The computer system of  claim 17 , wherein the predictive model is further responsive to values of co-morbidity data comprising at least two of (i) alcohol related co-morbidity information, (ii) drug related co-morbidity information, (iii) tobacco related co-morbidity information, (iv) arthritis related co-morbidity information, (v) diabetes related co-morbidity information, or (vi) obesity related co-morbidity information. 
     
     
         19 . The computer system of  claim 17 , wherein the current claim transaction is a worker's compensation claim. 
     
     
         20 . The computer system of  claim 17 , wherein the current claim transaction is a bodily injury claim.