METHOD AND SYSTEM FOR OPTIMIZING PROCESSING OF INSURANCE CLAIMS AND DETECTING FRAUD THEREOF

摘要

Embodiments of the present disclosure disclose a method for optimizing processing of insurance claims. The method comprises one or more steps performed by an insurance data processing apparatus. The method comprises examining completeness of information in an insurance application form to avail insurance claims for an insured patient. Then, the information contained in the insurance application form is segmented into at least one of medical data and behavioural data of the insured patient. Next, one or more diseases from the medical data into a medical group and behavioural parameters from the behavioural data are classified into a behavioural group. The classification is performed using predefined one or more ontologies comprising medical ontologies and behavioural ontologies. Then, a relevancy of the insurance claims associated to the insured patient is verified based on the classification of the one or more diseases and the behavioural parameters.

主权项

1. A method for optimizing processing of insurance claims, the method comprising:
examining, by an insurance data processing apparatus, completeness of information in an insurance application form to avail insurance claims for an insured patient; segmenting, by the insurance data processing apparatus, the information contained in the insurance application form into at least one of medical data and behavioural data of the insured patient; classifying, by the insurance data processing apparatus, one or more diseases from the medical data into a medical group and behavioural parameters from the behavioural data into a behavioural group, wherein the classification is performed using predefined one or more ontologies comprising medical ontologies and behavioural ontologies; and verifying, by the insurance data processing apparatus, a relevancy of the insurance claims associated to the insured patient based on the classification of the one or more diseases and the behavioural parameters.