A Methodology to Support BPM for a Health Insurer
Summary:
Doreen Evans Associates partnered with a health insurance client to illustrate how the DEA methodology could help them achieve their BPM goals.
Client Profile:
A major publicly-traded health insurer that provides health care benefits to millions of people.
The Challenge:
The company was charged with simplifying, consolidating, and standardizing business processes and technology systems without compromising its ability to deliver quality service. The enterprise was charged with moving toward a common platform and tasked the IT group to conduct a gap analysis between their existing claim management system and a potential replacement. After completing the gap analysis, management recognized the need to significantly improve their internal business process management (BPM) skill sets and to develop BPM methodologies.
The new infrastructure would empower future project teams with (1) a business process modeling strategy, (2) a current state business process baseline that would provide an understanding of existing system capabilities and their linkages to the business process they support, and (3) future state business processes providing the organization with an understanding of future system capabilities and their linkages to the business process they support.
The Solution:
The objective of the project was to capitalize on the capabilities, methodology and tools which DEA offers. The project was performed as a pilot in order to test the approach and the tools.
The project’s focus began with analyzing the Authorization Request Process and the Pended Claims Resolution Process – specifically those claims pended for authorization and coordination of benefits (COB) issues. DEA and client team members documented and analyzed the current business processes, identified opportunities for improvement, and developed future process models. These models were annotated to illustrate opportunity areas, and a thorough evaluation of each task’s timing and metrics was performed. A cost-benefit was performed and a focus area was selected for requirements analysis and documentation. Some new functionality was specified, as well as enhancements to existing functionality. The coordinated team developed use case models for the system functions and documented detailed system requirements, including user interface requirements, business rules, and interfaces to other systems.
A repository based modeling tool was used throughout the engagement to store and manage the information collected. DEA’s customized RequirementsLINK™ tool was used to publish the information to the web for team collaboration and management approval. Using this tool, team members could see the linkages from the business process through to specific system functions. It quickly became clear where system improvements would bring the most benefit.
