Patent ID: 11900473
Assignee: BRIGHTERION, INC.
Field: IT methods for management (Electrical engineering)
Classification: CPC G  Y | IPC G

Claim 6:
7. At least one network server for healthcare fraud detection, the at least one network server comprising:
one or more processors;
non-transitory computer-readable storage media having computer-executable instructions stored thereon, wherein when executed by the one or more processors the computer-readable instructions cause the one or more processors to—
receive a healthcare payment request corresponding to a healthcare provider;
match the healthcare payment request to a smart agent having a profile comprising a representation of historical data of the healthcare provider;
compare the contents of at least one data field of the healthcare payment request against the profile of the corresponding smart agent and, based at least in part on the comparison, generate a first output indicative of a determination of likely fraud;
generate a second smart agent having a second profile by unsupervised clustering of a group of healthcare providers based on at least one claim attribute;
match the healthcare payment request to the second smart agent having the second profile;
compare the contents of at least one data field of the healthcare payment request against the second profile of the corresponding second smart agent and, based at least in part on the comparison, generate a second output indicative of a determination of unlikely fraud;

analyze the first output and the second output and generate a decision on the healthcare payment request based at least in part on the analysis, the analysis including determining that the first output meets a first criteria indicating fraud or abuse, determining that the second output meets a second criteria indicating acceptable behavior within the corresponding group, and determining that the second output overrides the first output,
wherein the decision comprises an approval decision for the healthcare payment request.