Challenge
A customer care system faced significant challenges in processing claims efficiently and accurately. These challenges included:
- Manual Data Entry: Customer service representatives manually entered claim data from phone calls, leading to potential errors and time-consuming processes.
- Lack of Real-time Validation: The system lacked real-time validation of customer data and claim eligibility, resulting in delayed decisions and the need for rework.
- Integration with External Systems: Verifying customer information, such as insurance program eligibility, required integration with multiple third-party systems.
- Complex Decision Logic: Determining claim approval or rejection involved complex decision logic based on treatment types and customer-provided information.
- Dynamic Decision-Making: The need to dynamically adjust decision trees based on customer responses added further complexity.
Solution
The organization implemented an Appian-based solution to automate and streamline the claim processing system. This solution leveraged Appian’s low-code capabilities, process management features, and integration tools to address the identified challenges.
Key Features and Implementation Details
- Web API Integration: Appian’s Web API functionality enabled seamless integration with various systems, allowing data to be entered from any system.
- Pre-determination of Claim Processing: The system automates the pre-determination of claim processing, speeding up the overall process.
- Eligibility Verification: Appian automatically verifies claim eligibility based on treatment types and customer data.
- Case Management System: Appian’s case management capabilities provide a centralized platform for managing and tracking claims throughout their lifecycle.
- Real-time Data Validation: As customer service representatives enter data, the system instantly validates the information, ensuring accuracy and reducing errors.
- Third-Party Integrations: Appian integrates with external systems (e.g., insurance databases) to validate customer details like date of birth and program eligibility in real-time.
- Dynamic Decision Trees: The system utilizes Appian’s business rules engine to create dynamic decision trees that adapt based on customer responses. This allows for flexible and personalized claim processing.
- The decision trees are built based on customer responses, allowing the system to dynamically adjust the approval process.
- Approval decisions are based on the dynamically generated decision tree.
Results
The implementation of the Appian solution resulted in significant improvements:
- Increased Efficiency: Automated data entry, real-time validation, and streamlined workflows reduced claim processing time.
- Improved Accuracy: Automated validation and third-party integrations minimized data entry errors and improved the accuracy of eligibility determinations.
- Faster Decision-Making: Real-time validation and dynamic decision trees enabled faster claim approvals or rejections.
- Enhanced Customer Satisfaction: Quicker processing times and more accurate decisions led to improved customer satisfaction.
- Reduced Costs: Automation reduced the need for manual processing and decreased operational costs.
- Greater Flexibility: Dynamic decision trees provided the flexibility to adapt to changing business rules and customer needs.
Conclusion
By leveraging Appian’s low-code platform, the organization successfully transformed its claim processing system. The solution automated key processes, integrated with external systems, and implemented dynamic decision-making capabilities. This resulted in increased efficiency, improved accuracy, faster decision-making, and enhanced customer satisfaction. Appian’s flexibility and scalability make it an ideal platform for organizations seeking to optimize complex case management processes.