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Boost Straight Through Processing in Your Claims System

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Learn how you can automate decisions to handle more claims without manual intervention and apply advanced analytics and AI to detect fraud and manage waste.
How claims are handled is central to the customer experience and to controlling expenses. Effective decision automation reduces costs while improving service, regardless of your core claims system.

Publicado en: Empresariales
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Boost Straight Through Processing in Your Claims System

  1. 1. @jamet123 #decisionmgt © 2017 Decision Management Solutions James Taylor, CEO Boost Straight Through Processing in Your Claims System with Decision Automation
  2. 2. @jamet123 #decisionmgt © 2017 Decision Management Solutions 2 Your Goals ▶ Automatically handle more claims ▶ While controlling risk and reducing fraud ▶ By building a claims handling solution
  3. 3. @jamet123 #decisionmgt © 2017 Decision Management Solutions 3 This Webinar Will Help You ▶ Identify the technologies you need ▶ To build claims handling systems ▶ Understand the best approach ▶ So you can get a successful implementation quickly ▶ And build claims handling systems that ▶ Improve customer satisfaction ▶ Reduce costs ▶ Control risk ▶ Manage fraud ▶ Automate more claims
  4. 4. @jamet123 #decisionmgt © 2017 Decision Management Solutions 4 A Real Example: From Digital To Jet Integrate And Deploy Integrate into production Complete pilot review Test and roll-out Finalize Decision Service Complete decision model Add remaining rules and analytics QA, test and simulate Demonstrate Approach Develop test and simulation data Integrate with demo environment Show potential Iterate And Integrate Extend top-down decision model Add business rules to decisions Add analytics to decisions Develop Initial Decision Models Analyze existing materials Determine approach Define claims handling decision
  5. 5. @jamet123 #decisionmgt © 2017 Decision Management Solutions 5 Key To Success: Decisions First ▶ It doesn’t matter how efficient your process is… ▶ If you pay the wrong claims ▶ Straight Through Processing depends on your Claims Handling decision ▶ Which claims to approve ▶ Which claims to decline ▶ When to investigate ▶ Who to assign claims to ▶ To succeed, think first about the decision ▶ Not the process
  6. 6. @jamet123 #decisionmgt © 2017 Decision Management Solutions 6 A Great Claims Handling Solution
  7. 7. @jamet123 #decisionmgt © 2017 Decision Management Solutions 7 Three Claims Cost Drivers The three big drivers of cost in claims handling are: Jet or straight through processing rate. The more claims you handle automatically, the lower the cost How long it takes to handle the rest of the claims and how expensive a person it requires How much wastage and outright fraud you end up paying for
  8. 8. @jamet123 #decisionmgt © 2017 Decision Management Solutions 8 Claims Handling Drives Customer Satisfaction Claims are one of the most important elements in determining customer satisfaction Customers really want you to pay their claims and pay them quickly – they need the money More auto payment, less time to pay, fewer problems, better explanations – all increase satisfaction
  9. 9. @jamet123 #decisionmgt © 2017 Decision Management Solutions 9 A Great Claims Handling Solution Speeds Claims Controls for Risk Manages Fraud and Waste Enforces Compliance You need a solution that auto pays as many claims as possible while controlling for risk by considering important customers and assigning to the right people so it focuses experience and expensive investigators where this makes a difference. You need a solution that prevents fraud and waste from being paid and constantly refines, adapts and improves. Plus you need to be able to demonstrate compliance with a consistent, accurate and legal approach
  10. 10. @jamet123 #decisionmgt © 2017 Decision Management Solutions 10 Elements of a Great Claims Handling Solution
  11. 11. @jamet123 #decisionmgt © 2017 Decision Management Solutions 11 Five Elements For Claims Handling Success Continuous Improvement Advanced Analytics Decision Service Decision Model Managed Business Rules
  12. 12. @jamet123 #decisionmgt © 2017 Decision Management Solutions 12 Claims Handling Decision Model Clear Understanding, Business Ownership A decision model shows all the elements of the claims handling decision and how they interact It is based on the real experience of your claims adjustors, combined with your policies, regulatory environment and best practices A simple notation allows it to be “owned” by your claims team and the use of an industry standard (DMN) future-proofs it
  13. 13. @jamet123 #decisionmgt © 2017 Decision Management Solutions 13 Claims Handling Business Rules Easy Management Simple representations of the logic for each piece of the decision make it easy for business experts to make changes The decision model makes it easy for them to find the logic they need to change without having to learn a new repository structure.
  14. 14. @jamet123 #decisionmgt © 2017 Decision Management Solutions 14 Claims Handling Business Rules Safe Agility and Impact Analysis Before making any change, business owners can easily simulate the impact of their changes and make sure they are clear on the context of the change. The decision model shows what needs to be simulated and easy access to simulation reduces errors and gives business owners the confidence to make the changes they need. Changes can be identified, proposed, simulated and confirmed rapidly so the claims handling decision never falls behind regulators or fraudsters
  15. 15. @jamet123 #decisionmgt © 2017 Decision Management Solutions 15 Advanced Analytics In Claims Handling Advanced analytics that predict fraud or wastage can be combined with explicit red-flag rules and leverage data, machine learning and even AI to improve the accuracy of your decisions. Detect more fraud, spot more wastage while keeping business control of the overall decision.
  16. 16. @jamet123 #decisionmgt © 2017 Decision Management Solutions 16 Continuous Claims Handling Improvement The structure of the decision model shows exactly what data is needed to review the effectiveness of the decision and see how it might be improved. Capturing this data allows for decision-centric dashboards to support continuous improvement by the business
  17. 17. @jamet123 #decisionmgt © 2017 Decision Management Solutions 17 Consistent Agile Claims Handling Deploying the whole package of decision model, business rules and analytics as a decision service, a service that just makes claims handling decisions, allows all your claims processing systems and processes to share accurate, agile decision-making External Data Big Data Business Rules Continuous Improvement Analytics and AI
  18. 18. @jamet123 #decisionmgt © 2017 Decision Management Solutions 18 These Five Elements Deliver A Great Claims Handling Solution Speed Claims Control for Risk Manage Fraud and Waste Enforce Compliance Continuous ImprovementAdvanced Analytics Managed Business Rules Decision ServiceDecision Model The decision model shows what can be automated, the business rules automate it and deployment as a decision service let’s all your systems take advantage of it. The decision model reveals the role of advanced analytics (and AI), framing the problem so your data can be used to solve it Modeling the decision reveals the drivers of risk, allowing you to manage them with the right rules. Ongoing review of the risk that results allows you to improve continuously The transparency of a decision model and its supporting business rules ensure demonstrable compliance, enforced everywhere using your decision service.
  19. 19. @jamet123 #decisionmgt © 2017 Decision Management Solutions 19 Thank You ▶ More resources for success with Customer Next Best Action ▶ Decision Management Solutions works with clients to improve their business by applying business rules & analytic technology to automate & improve decisions We can help you rapidly design and build a claims handling solution for your business.