Predictive Modeling Using Corticon BRMS

A leading provider of technology-enabled claim management services, risks and benefits solutions

Leading provider of technology-enabled claim management services, risks and benefits solutions.

The Client

One of the leading provider of technology-enabled claim management services, risks and benefits solutions. Our client delivers cost-effective claims, productivity, managed care, risk consulting and other services. Also facilitates financial and personal health and helps customers and consumers navigate complexity by designing and implementing customized programs based on proven practices and advanced technologies.

The Challenge

Original process was using a specific dynamic query that run on monthly basis to extract data related to claims. These extracted files information were used to create SAS reports based on a percentile score that helped to identify and distinguish various claim. These generated SAS reports were then sent to supervisor for analysis, monitoring /taking appropriate proactive actions.

There were few constrain on that process such us identified claims were reviewed by the team lead only at day 30 as the process are run only on a month basis. Process involved heterogeneous systems and manual intervention as files created in system of records are transferred to SAS and run through model to get the report which are then emailed to supervisors. Categorization of claims followed a 30 day cycle, Critical claims were discovered on 30th day, delays the whole cycle of proactive action. EXPEDITE THE EARLY DETECTION OF CRITICAL CLAIMS AND IMPROVE OPERATIONAL EFFICIENCY

The Solution

Project was conceptualized to convert the existing system into true automated predictive modelling system using Corticon BRMS and OpenEdge. Goal of new system is to enhance the capability to look for all open claims in the system, then calculate a predictive score based on rules defined for the predictive analytics model and identify or predict whether a claim belongs to a certain category or not. New process runs daily and in case there is any change to any critical claim field, then that claim is rescored. System have the capability to alert the authorized user regarding the potential critical category of the claim.

The Benefits

The predictive analytics capability enabled client’s claim examiners or an authorized user to identify a potential critical category of claim early on to help take proactive decisions / actions, bringing business value.

  • Business Intelligence – Analytics team have new capability to identify potential critical claim.
  • Reduce operational costs as now the task of identifying the potential high-risk claims is automated.
  • Increase organizational agility – Compressed the change cycle from months to days.
  • Generate faster result.
  • Automated Task.
  • Easy to change.
  • Business analysts can view the rules implemented for a model.
  • The project was awarded in CIO 100 event in Colorado Spring, USA in August 2017.