bbc 2012 - decision management (deloitte)
DESCRIPTION
Two large insurance organizations adopted business rules to develop a single system that delivered straight through processing and more agility. They extracted more than 3000 rules from legacy systems, compressed them into 500 rules and mapped them to businesses processes. But this left them with gaps in their processes and not as much reuse as they hoped. The project team determined that they had missed a key step - defining the decisions. Without clear decision definitions it was hard to work effectively with business processes or rules. This presentation outlines what the project team did to rectify the situation.TRANSCRIPT
BBC 2012
Business Rules Successwith Decision Management
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Agenda
In The Beginning
First Steps Into Rules
Separating Flow from Know
Enter Decision Management
The Decision Lifecycle Begins
2 BBC 2012: Business Rules Success with Decision Management
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In The Beginning
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In The Beginning
Two large health insurance organizations
Two antiquated claim processing systems
No documented processes or rules
IT controlled all updates to business logic
Rising maintenance costs
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Situation
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In The Beginning
Similar business processes
Different business rules
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Findings
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In The Beginning
Synergies through process consolidation
Use the business rules approach
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Conclusion
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First Steps Into Rules
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First Steps Into Rules
Collected all rules into a spreadsheet
Initial collection was mainly from code
More than 6000 rules extracted
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Situation
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First Steps Into Rules
If
tariff is 78410, 78411, 78440, 78452, 78550, 78553, 78554, 78556, 78557, 78559, 78595, 78596 and referring provider number bloc is 08 and hospital is zeros or spaces
Then
fail 25
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If
1st payer COB scenario and policyholder has HSA on 1st contract
Then
forward unpaid balance to HSA in pended status and also forward unpaid balance to 2nd COB contract.
During processing of the 2nd COB, if the full unpaid balance is paid, close the 1st HSA claim. If there is still an unpaid balance, update the 1st HSA claim with the new unpaid balance. (This is a manual process).
Examples from the initial extraction:
Situation
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First Steps Into Rules
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Rules highly tied to legacy system
Some rules were processes themselves
No process linkage identified
No analysis for patterns done Findings
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First Steps Into Rules
Separate processes and rules
Link rules in the big bucket to decision points
Write rules in business terms
Find more cross-company reuse
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Conclusion
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Separating Flow from Know
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Separating Flow from Know
Process diagrams created
Rules linked to decision points
Business level language used
Initial patterns and reuse opportunities found
Rule count dropped from 6000 to 500
13 BBC 2012: Business Rules Success with Decision Management
Situation
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Separating Flow from Know
If
tariff is 78410, 78411, 78440, 78452, 78550, 78553, 78554, 78556, 78557, 78559, 78595, 78596 and referring provider number bloc is 08 and hospital is zeros or spaces
Then
fail 25
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Before:
If
The claimed benefit catalogue item is "Consult" and the referring provider's specialty is “Pathology” and hospital is not given
Then
Reject the entire claim
After:
Situation
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Separating Flow from Know
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If
The claimed benefit catalogue item is "Consult" and the referring provider's specialty is “Pathology” and hospital is not given
Then
Reject the entire claim
Processes and rules linked:
Situation
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Separating Flow from Know
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Very deep processes
Findings
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Separating Flow from Know
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Process sequences not always qualified
Decision points were not described
Findings
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Separating Flow from Know
Lack of consistent vocabulary
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Findings
If
The benefit catalogue item is hospital stay benefit, and the patient is a paneled patient
Then
Reject portion of claim from paneled date to the end of claimed period
If
The following are all true:- claim is Real Time Drugs - the subscriber contract Last Paid Date is specified - the service date is greater than the subscriber contract Last Paid
Date
Then
Reject the entire claim
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Separating Flow from Know
Some rules were too abstract
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Findings
If
The service recipient is restricted to a provider and submitted provider is not the restricted provider
Then
Reject the entire claim
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Separating Flow from Know
Some rules were too abstract
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Findings
If
The service recipient is restricted to a provider and submitted provider is not the restricted provider
Then
Reject the entire claim
?
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Separating Flow from Know
Document decisions as dependencies
Decision inputs, outputs, goals needed
Common vocabulary required
Decomposition needed to create more reuse
Structuring of rules needed for accessibility
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Conclusion
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Enter Decision Management
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Decision dependencies analyzed
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Enter Decision Management
Situation
A
BC
D
EF
G
H
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Before
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Enter Decision Management
Situation
After
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Enter Decision Management
Decisions input, output and goal captured
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Situation
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Enter Decision Management
Right-hand side of rules (‘then’) analyzed to confirm content of decisions
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If
The claimed benefit catalogue item is "Consult" and the referring provider's specialty is “Pathology” and hospital is not given
Then
Reject the entire claim
If
If submitted benefit catalogue item requires specific provider which differs from submitted provider
Then
Reject the claim item
Situation
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Enter Decision Management
100 step process simplified into 14 steps
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Situation
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Enter Decision Management
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If
The claim is a reciprocal claim and the benefit is of type “Surgery – Oral”
Then
Reject the claim item
A claim is considered a reciprocal claim if the service recipient province is not “Nova Scotia”.
If
The claim is a reciprocal claim and the service date comes before the effective date of the provider
Then
Reject the entire claim
Situation
Reuse and clarity gained through decomposition
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Enter Decision Management
Rules analyzed for patterns and transformed into simpler formats
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If
The claimed benefit was received in “Pictou” and the referring provider's specialty is “Radiology”
Then
Premium is 14%
MunicipalityReferring Provider
SpecialityPremium
Cumberland Pathology 25%
Pictou Radiology 14%
Situation
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Enter Decision Management
Common vocabulary adopted
30 BBC 2012: Business Rules Success with Decision Management
Subscriber
Patient
Service Recipient
Situation
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Enter Decision Management
Decisions simplified the processes
Decisions organized the rules
Logic now business friendly and system ready
More business agility and accessibility
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Findings
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The Decision Lifecycle Begins
