Success stories
Healthcare Industry: Correspondence Tracking
Health insurance organization implements new risk-management system to provide proactive file maintenance and correspondence tracking
Scenario:
A leading health insurance company needed to implement new technology to manage risks associated with complaints and appeals. This new risk-management system had to provide proactive file maintenance and correspondence tracking, help to minimize penalties and assist in meeting established turn-around times. The new reporting component would provide accurate and real-time reporting for management and government officials.
Objectives:
Develop and implement a centralized data collection system to record, track and accurately report all complaint- and appeal-related activities.
IBM solution:
A development team created an application using existing desktop technology. The application incorporated a Web-based user interface and a central database repository. Ad-hoc reporting was provided to track, and show trends in, the complaints and appeals data. The customer uses IBM WebSphere® Business Integration Monitor to generate reports, which the customer uses to balance workloads proactively and report on "in-flight" and completed items.
IBM provided expert support in business process modeling, workflow integration, monitor development and implementation services. About 1,000 WebSphere Business Integration Monitor users and 10,000 WebSphere MQ Workflow users will be connected to this system when it is fully deployed.
Overview and results:
Delayed resolutions of complaints and appeals caused the company to incur large penalties. The penalties resulted from the manual processing of complaint and appeal correspondence with no real-time monitoring to proactively address outstanding items.
Against our recommendation, the customer decided to omit As-Is Process development and focus time, resources and energy on the development of the future process model.
The creation of the To-Be model proved to be quite a challenge--which could have been avoided if the As-Is model had been created and validated. The initial To-Be architecture and model did not depict all interdependencies between departments; embedded legacy processes added to the project participants' confusion. IBM worked with the business leaders to validate and modify the existing models to accurately depict all the required process steps and handoffs.
The company used the WebSphere Business Integration Monitor to generate historical and real-time reports for their front-line supervisors and management, which was critical to the success of the project. The customer used the WebSphere Business Integration Monitor to enhance the notification capabilities of WebSphere MQ Workflow. When a notification is "sent out" for a process executed by WebSphere MQ Workflow, the WebSphere Business Integration Monitor will display those notifications to all appropriate supervisors. By using the WebSphere Business Integration Monitor, the supervisors can take either administrative action on the work item (suspend, resume, transfer, etc.) or start a new process instance (from the WebSphere Business Integration Monitor) that sends the member a letter informing him or her of the delay.
Implemented technology:
The technology used to provide this solution was the WebSphere Business Integration Workbench, WebSphere Business Integration Monitor and WebSphere MQ Workflow product suite. The development team developed the application, user interfaces and standard messaging formats using WebSphere MQ.
Customer benefits:
This new architecture established clear organizational accountability for complaints and appeals in all business areas; improved customer satisfaction, minimized litigation / risk and provided consistent policy and practices to enable regional benchmarking. The workflow infrastructure provided by WebSphere MQ Workflow and its ability to be flexible and handle business routing rules effectively provides for quickly changing business environments. The WebSphere Business Integration Monitor reporting features allow the customer to use real-time reporting in order to manage work items proactively.
