BBC 2012 - Decision Management (Deloitte)
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BBC 2012 - Decision Management (Deloitte)

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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 ...

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.

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BBC 2012 - Decision Management (Deloitte) Presentation Transcript

  • 1. BBC 2012 Business Rules Success with Decision Management
  • 2. © Deloitte & Touche LLP and affiliated entities. Agenda In The Beginning First Steps Into Rules Separating Flow from Know Enter Decision Management The Decision Lifecycle Begins 1 BBC 2012: Business Rules Success with Decision Management
  • 3. © Deloitte & Touche LLP and affiliated entities.2 BBC 2012: Business Rules Success with Decision Management In The Beginning
  • 4. © Deloitte & Touche LLP and affiliated entities. 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 3 BBC 2012: Business Rules Success with Decision Management Situation
  • 5. © Deloitte & Touche LLP and affiliated entities. In The Beginning Similar business processes Different business rules 4 BBC 2012: Business Rules Success with Decision Management Findings
  • 6. © Deloitte & Touche LLP and affiliated entities. In The Beginning Synergies through process consolidation Use the business rules approach 5 BBC 2012: Business Rules Success with Decision Management Conclusion
  • 7. © Deloitte & Touche LLP and affiliated entities.6 BBC 2012: Business Rules Success with Decision Management First Steps Into Rules
  • 8. © Deloitte & Touche LLP and affiliated entities. First Steps Into Rules Collected all rules into a spreadsheet Initial collection was mainly from code More than 6000 rules extracted 7 BBC 2012: Business Rules Success with Decision Management Situation
  • 9. © Deloitte & Touche LLP and affiliated entities. 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 8 BBC 2012: Business Rules Success with Decision Management 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
  • 10. © Deloitte & Touche LLP and affiliated entities. First Steps Into Rules 9 BBC 2012: Business Rules Success with Decision Management Rules highly tied to legacy system Some rules were processes themselves No process linkage identified No analysis for patterns doneFindings
  • 11. © Deloitte & Touche LLP and affiliated entities. 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 10 BBC 2012: Business Rules Success with Decision Management Conclusion
  • 12. © Deloitte & Touche LLP and affiliated entities.11 BBC 2012: Business Rules Success with Decision Management Separating Flow from Know
  • 13. © Deloitte & Touche LLP and affiliated entities. 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 12 BBC 2012: Business Rules Success with Decision Management Situation
  • 14. © Deloitte & Touche LLP and affiliated entities. 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 13 BBC 2012: Business Rules Success with Decision Management 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
  • 15. © Deloitte & Touche LLP and affiliated entities. Separating Flow from Know 14 BBC 2012: Business Rules Success with Decision Management 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
  • 16. © Deloitte & Touche LLP and affiliated entities. Separating Flow from Know 15 BBC 2012: Business Rules Success with Decision Management Very deep processes Findings
  • 17. © Deloitte & Touche LLP and affiliated entities. Separating Flow from Know 16 BBC 2012: Business Rules Success with Decision Management Process sequences not always qualified Decision points were not described Findings
  • 18. © Deloitte & Touche LLP and affiliated entities. Separating Flow from Know Lack of consistent vocabulary 17 BBC 2012: Business Rules Success with Decision Management 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
  • 19. © Deloitte & Touche LLP and affiliated entities. Separating Flow from Know Some rules were too abstract 18 BBC 2012: Business Rules Success with Decision Management Findings If The service recipient is restricted to a provider and submitted provider is not the restricted provider Then Reject the entire claim
  • 20. © Deloitte & Touche LLP and affiliated entities. Separating Flow from Know Some rules were too abstract 19 BBC 2012: Business Rules Success with Decision Management Findings If The service recipient is restricted to a provider and submitted provider is not the restricted provider Then Reject the entire claim ?
  • 21. © Deloitte & Touche LLP and affiliated entities. 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 20 BBC 2012: Business Rules Success with Decision Management Conclusion
  • 22. © Deloitte & Touche LLP and affiliated entities.21 BBC 2012: Business Rules Success with Decision Management Enter Decision Management
  • 23. © Deloitte & Touche LLP and affiliated entities. Decision dependencies analyzed 22 BBC 2012: Business Rules Success with Decision Management Enter Decision Management Situation A B C D E F G H
  • 24. © Deloitte & Touche LLP and affiliated entities. Before 23 BBC 2012: Business Rules Success with Decision Management Enter Decision Management Situation After
  • 25. © Deloitte & Touche LLP and affiliated entities. Enter Decision Management Decisions input, output and goal captured 24 BBC 2012: Business Rules Success with Decision Management Situation
  • 26. © Deloitte & Touche LLP and affiliated entities. Enter Decision Management Right-hand side of rules (‘then’) analyzed to confirm content of decisions 25 BBC 2012: Business Rules Success with Decision Management 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
  • 27. © Deloitte & Touche LLP and affiliated entities. Enter Decision Management 100 step process simplified into 14 steps 26 BBC 2012: Business Rules Success with Decision Management Situation
  • 28. © Deloitte & Touche LLP and affiliated entities. Enter Decision Management 27 BBC 2012: Business Rules Success with Decision Management 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
  • 29. © Deloitte & Touche LLP and affiliated entities. Enter Decision Management Rules analyzed for patterns and transformed into simpler formats 28 BBC 2012: Business Rules Success with Decision Management If The claimed benefit was received in “Pictou” and the referring provider's specialty is “Radiology” Then Premium is 14% Municipality Referring Provider Speciality Premium Cumberland Pathology 25% Pictou Radiology 14% Situation
  • 30. © Deloitte & Touche LLP and affiliated entities. Enter Decision Management Common vocabulary adopted 29 BBC 2012: Business Rules Success with Decision Management Subscriber Patient Service Recipient Situation
  • 31. © Deloitte & Touche LLP and affiliated entities. Enter Decision Management Decisions simplified the processes Decisions organized the rules Logic now business friendly and system ready More business agility and accessibility 30 BBC 2012: Business Rules Success with Decision Management Findings
  • 32. © Deloitte & Touche LLP and affiliated entities.31 BBC 2012: Business Rules Success with Decision Management The Decision Lifecycle Begins