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Live from DIALOG – Breakthrough in Claims Excellence Management


Last session of the day was from Rodolfo Viola of Swiss Medical Argentina on Breakthrough in Claims Excellence Management. Claims is, of course, a prime target for rules-based automation so I was excited to hear how an organization outside of North America/Europe was handling it.

Swiss Medical is a privately owned company founded as a clinic and expanded through merger and acquisitions. Now have more than 650,000 individuals covered and the claims processing system must handle more kinds of treatment as clinics are added. Most of the covered individuals are employees of multinationals. They have more than 60,000 practitioners spread over 1,200 clinics and 3,000 other centers. Every practitioner has a different contract with Swiss Medical!

The process is Claims Control and Payment to Practitioners. The old process was manual, duplicatative, slow, siloed and highly centralized. Speed was a real issue not just because practitioners disliked delays in payment but because VAT can only be recovered if requested in 15 days. Old process had exposure to errors due to misinterpretation but also due to collusion between employees and clinics – fraud. They need to process 2M claims a month covering $260M. Analysis of this showed:

  • 57% of these were very simple and ought to be automatic, therefore.
  • 2% of practitioners represent 50% of costs.
  • 3,000 treatments were not in the catalog and 60% of new treatments were classed as “emergency” and so not controlled.
  • Not all of the practitioners had contracts.
  • 10% of coverage plans handle 80% of the individuals covered – some plans had 1 covered individual!

CLEX – the Claims Excellence Management project – was focused on paperless, correctly handle government reimbursement, reduce fraud and eliminate errors, reduce time to process and FTEs needed. The project designed a new to-be process based on these principles. Solution had three layers:

  • Sustainable change transformational layer at the top
  • Layer of KPIs and performance management at the bottom
  • Standard Claims Excellent initiative – a focus on accuracy and efficiency. Decisions: Should this be paid, Is this fraud, Should the government pay etc.

They identified many kinds of rules around fraud, audit, pre-existing conditions, reimbursement, levels of care and so on. The process was an integrated, straight through sequence of

  1. Authorization
  2. Eligibility – This is where JRules is used – the Spanish version.
  3. Claims Processing
  4. Control and Pricing
  5. Payment Processing

The architecture is based around an Enterprise Service Bus and additional features, like authorization, are being added and reusing the rules. They continue to add more practitioners and reviewing rules to refine them and to add more rules to handle more sophisticated claims. JRules is going to also support a Point of Sale system for practitioners as well as authorizations and reimbursements. Lessons learned during the two year project include:

  • Prepare a full blue print, start with a small pilot (plan big, start small)
  • Increase volume slowly in order to be sure of compliance and integration
  • Don’t shortcut requirements to hit the original target date – it will be more expensive in the end
  • IT involvement is critical from the beginning but….
  • Must not be an IT project
  • MUST be a USER tool
  • Include rules as part of each business process – though I would say include DECISIONS as part of the process
  • Plan for change management and re engineering in advance as you will need it

A great summary of how to do claims and how to use a business rules management system to make a process run straight-through. Particularly liked his point that some of the rules they found were not being applied and that $3M could be recovered in a single year! Very cool.

I will post a wrap up and some notes from my lunches with Sandy Carter and with ILOG customers in the next day or so. Don’t forget to look for more posts on DIABLOG. To the airport….