Systems and methods for using trained predictive modeling to reduce misdiagnoses of critical illnesses

A method for determining that a diagnosis and treatment plan is inaccurate and performed by a trained predictive server including a processor and a memory, the method comprising:

• receiving a set of prior authorization (PA) data associated with a medical claim for a patient;
• determining that the set of PA data indicates that the medical claim is associated with a qualifying critical illness;
• extracting component data from the set of PA data;
• applying the extracted component data to a trained predictive model associated with the qualifying critical illness to determine whether the medical claim is associated with an inaccurate diagnosis and treatment plan;
• and
• upon determining that the medical claim is associated with the inaccurate diagnosis and treatment plan, generating a request for a consulting review of the diagnosis and treatment plan using the set of PA data.

A trained predictive system for determining that a diagnosis and treatment plan is inaccurate, said trained predictive system comprising:

• a first claim database server comprising a database processor and a database memory, the database memory includes a set of prior authorization (PA) data associated with a medical claim for a patient, the database processor configured to determine that the set of PA data indicates that the medical claim is associated with a qualifying critical illness;
• and
• a trained predictive server in communication with the first claim database server, the trained predictive server comprising a processor and a memory, the processor configured to:
• receive the set of PA data associated with the medical claim for the patient from the first claim database server;
• extract component data from the set of PA data;
• and
• apply the extracted component data to a trained predictive model associated with the qualifying critical illness to determine whether the medical claim is associated with an inaccurate diagnosis and treatment plan;
• and
• wherein the database processor is further configured to:
• receive an indication that the medical claim is associated with the inaccurate diagnosis and treatment plan from the trained predictive server;
• and
• generate a request for a consulting review of the diagnosis and treatment plan using the set of PA data.