Boost Straight Through Processing in Your Claims System

@jamet123 #decisionmgt © 2017 Decision Management Solutions
James Taylor, CEO
Boost Straight Through Processing in
Your Claims System with Decision
Automation

@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

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

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

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

A Great Claims Handling Solution

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

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

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

Elements of a
Great Claims Handling Solution

Five Elements For Claims Handling Success
Continuous
Improvement
Advanced
Analytics
Decision
Service
Decision
Model
Managed
Business Rules

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

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.

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

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.

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

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

These Five Elements Deliver
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.

Thank You
▶ More resources for success with
Customer Next Best Action
▶ http://bit.ly/DMSClaims
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.

Boost Straight Through Processing in Your Claims System

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