SYSTEMS AND METHODS FOR SETTLING DISPUTED CLAIMS

Abstract

Systems and methods for settling disputed claims and avoiding arbitration are provided. A set of settled medical claims is used to train a model to predict the settlement amount of a medical claims based on a variety of attributes of the claim. Later, when an insurance payor disputes a claim sent by a medical provider, the model is used to predict a settlement amount based on the attributes of the disputed claim. This predicted settlement amount is then sent to the payor and the medical provider as a proposed settlement amount for the disputed claim in a user interface. The medical provider and payor can either accept the proposed settlement amount or can provide a counter settlement amount through the user interface. Once both parties agree on the settlement amount, the disputed claim is settled and arbitration is avoided.

Description

Claims

1. A method comprising: receiving an indication that a claim is disputed by a computing device, wherein the claim is associated with a plurality of attributes, a requested payment amount, a payor, and a medical provider;in response to the determination, determining a predicted settlement amount for the claim based on the attributes associated with the claim;presenting the predicted settlement amount to the payor and the medical provider by the computing device;receiving from the payor and the medical provider an acceptance of the predicted settlement amount by the computing device; andsettling the claim for the predicted settlement amount by the computing device.

2. The method of claim 1, further comprising: storing a plurality of settled claims, wherein each settled claim is associated with a plurality of attributes, and a settlement amount; andtraining a model to predict settlement amounts for claims using the stored plurality of settled claims by the computing device.

3. The method of claim 1, further comprising determining the predicted settlement amount for the claim based on the attributes associated with the claim and the model.

4. The method of claim 1, wherein the computing device is associated with a claims clearinghouse.

5. The method of claim 1, further comprising: receiving a counter settlement amount to the predicted settlement amount from the medical provider;presenting the counter settlement amount to the payor;receiving an acceptable of the counter settlement amount from the payor; andsettling the claim for the counter settlement amount.

6. The method of claim 1, further comprising presenting the predicted settlement amount to the payor and the medical provider in a user interface provided by the computing device.

7. A method comprising: receiving a plurality of settled claims by a computing device, wherein each claim is associated with a plurality of attributes, and a settlement amount by the computing device;training a model to predict settlement amounts for claims using the stored plurality of settled claims by the computing device;receiving a claim by the computing device from a provider, wherein the received claim is associated with a plurality of attributes and includes a requested payment amount;using the attributes associated with the received claim and the model, predicting a settlement amount for the received claim by the computing device;determining that the requested payment amount exceeds the predicted settlement amount by the computing device; andin response to the determination, alert the provider that the received claim may be disputed.

8. The method of claim 7, wherein the provider is medical provider.

9. The method of claim 7, wherein the computing device is associated with a claims clearinghouse.

10. The method of claim 7, wherein determining that the requested payment amount exceeds the predicted settlement amount comprises determining that the requested payment amount exceeds the predicted settlement amount by more than a threshold.

11. The method of claim 7, wherein the received claim is received through a user interface, and alerting the provider that the received claim may be disputed in the user interface.

12. The method of claim 7, further comprising recommending that the provider change the requested payment amount to the predicted settlement amount in the alert.

13. The method of claim 7, wherein the plurality of settled claims are claims settled by a medical claim clearinghouse for a plurality of payors and a plurality of medical providers.

14. A system comprising: at least one computing device; anda computer-readable medium storing computer executable instructions that when executed by the at least one computing device cause the at least one computing device to: receive a plurality of settled claims, wherein each claim is associated with a plurality of attributes, and a settlement amount by the computing device;train a model to predict settlement amounts for claims using the stored plurality of settled claims;receive a claim from a provider, wherein the received claim is associated with a plurality of attributes and includes a requested payment amount;using the attributes associated with the received claim and the model, predict a settlement amount for the received claim;determine that the requested payment amount exceeds the predicted settlement amount; andin response to the determination, alert the provider that the received claim may be disputed.

15. The system of claim 14, wherein the provider is medical provider.

16. The system of claim 14, wherein the at least one computing device is associated with a claims clearinghouse.

17. The system of claim 14, wherein determining that the requested payment amount exceeds the predicted settlement amount comprises determining that the requested payment amount exceeds the predicted settlement amount by more than a threshold.

18. The system of claim 14, wherein the received claim is received through a user interface, and alerting the provider that the received claim may be subject to the arbitration in the user interface.

19. The system of claim 14, further comprising recommending that the provider change the requested payment amount to the predicted settlement amount in the alert.

20. The system of claim 14, wherein the plurality of settled claims are claims settled by a medical claim clearing house for a plurality of payors and a plurality of medical providers.