sap netweaver decision service management in sap for ......decision-making logic used within sap for...
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SAP NetWeaver Decision Service Management
in SAP for Insurance Claims Management Gerd Rühle
Global Head of Solution Management Health Insurance
SAP AG
Dr. Wolfgang Schaper
Solution Manager SAP NetWeaver Decision Service Management
SAP AG
© 2013 SAP AG. All rights reserved. 2
Health Insurance is Complex Many decisions need to be made and kept up to date on short notice
“My base coverage is with
my employer”
“I am mandatorily insured at
the federal state’s health
insurer where I work at”
“I can chose between Private
and statutory health insurance”
“I have to stay in my network.
Otherwise it is getting real real
expensive”
“I have to pay my treatments by
myself and get reimbursed”
“I do not care about money. I
just go and get the treatment. ”
“I already know at the POS
what is my cost share”
“I already exhausted my
deductible now. Where else can
I go to ?”
© 2013 SAP AG. All rights reserved. 3
SAP NetWeaver Decision Service Management
Co
nn
ec
tor
Managed System 1 (e.g. CRM)
Managed System 2 (e.g. ECC)
Decision Service Manager
Co
nn
ec
tor
Superior Technology
Decision Service Manager provides access to
metadata, code and values (master data, customizing)
to Managed Systems such as ECC or CRM for
“local” modeling
From the modeled service, Decision Service
Manager compiles an executable service on the
Managed System for local execution
The managed system does not require upgrades (or
Support Packages); Decision Service Manager can
be upgraded independently
Immediate Business Value / ROI
Rapid change cycles in the hand of the domain
experts
Analyze, Optimize, Implement; service execution
testing, tracing, analytics
No IT involvement, no downtime, planned service
availability, test deployments to any number of
systems
Automated business decisions with full transparency
for better decision quality
© 2013 SAP AG. All rights reserved. 4
SAP NetWeaver Decision Service Management Adds value to the entire claims value chain
File &
Document
Handling
Notification Eligibility
Determination
Benefit
Calculation Payment
Decision
Service:
Which
communication
channel to choose for
the notification?
Decision
Service:
Is the application
complete and
coherent?
Decision
Service:
Is the applicant
eligible for the
requested claim?
Decision
Service:
What is the correct
benefit amount?
Decision
Service:
How to pay out the
benefit?
All insurance companies run the same processes …
… differentiation happens in the decisions
© 2013 SAP AG. All rights reserved. 5
File & Document Handling Supported by SAP NetWeaver Decision Service Management
Files are received and have to be returned to
providers or forwarded to 3rd party administrators
SAP NW Process
Integration (PI)
for handling
technical checks
File &
Document
Handling
Notification Eligibility
Determination
Benefit
Calculation Payment
Claim
File
SAP Automated
Interface
Framework (AIF)
for handling
business checks
Notification
Decision Service
for SAP AIF
© 2013 SAP AG. All rights reserved. 6
Checks depending on file type and policy
contract need to be performed to ensure
data consistency for follow up steps
Decision Service
Notification
Ruleset Request for Approval
Family relationship between provider
and insured?
Provider allowed for prescription?
…
Ruleset Hospital Admission
Look up for approval if no emergency
case
Ruleset Invoice
Social security number in correct
format?
…
Ruleset …
…
File &
Document
Handling
Notification Eligibility
Determination
Benefit
Calculation Payment
Notification Complex cross checks by SAP NW Decision Service Management
© 2013 SAP AG. All rights reserved. 7
Eligibility Determination An ideal playground for SAP NW Decision Service Management
Eligibility as a sequence of YES-NO
questions built as an SAP NW Decision
Service Management orchestrated
sequence of Boolean decisions
■ Managed directly in the business department
Decision Service
Eligibility
Determination
Ruleset General Health
Policy Contract active?
Combination of diagnosis and
procedure allowed?
…
Ruleset Individual Health
…
Ruleset General Group Health
Subscriber contract active?
…
Ruleset Group Health
Employer XY
Subscriber contract active?
…
Ruleset …
…
File &
Document
Handling
Notification Eligibility
Determination
Benefit
Calculation Payment
© 2013 SAP AG. All rights reserved. 8
Benefit Calculation Hit the spot usage of SAP NW Decision Service Management
Focused decision making support along
the benefit calculation steps is a highlight
of SAP NW Decision Service Management
■ This includes evaluating data constellations that
require claim handler intervention and providing
input for subsequent calculation steps
Testing can be done in the productive
system with actual master data
■ There is no need for data replication
Decision Services
for
Benefit
Calculation
Ruleset General Support
Create task for claim handler
intervention
Create Claim Log entry
…
Ruleset Deductible Support
What is the open amount per year of
the deductible?
…
Ruleset Limit Support
In a quarter only 3 procedures are
allowed
…
Ruleset …
…
File &
Document
Handling
Notification Eligibility
Determination
Benefit
Calculation Payment
© 2013 SAP AG. All rights reserved. 9
Decision Service Modeling Empower business experts to control decision services
Allow business experts to
react faster to changing
business needs while
reducing the workload of IT
staff
Business-user friendly modeling
environment, e.g. supporting
decision tables, decision trees,
natural language like business
rules
© 2013 SAP AG. All rights reserved. 10
Debugging Rules Execution
The entire end-to-end
eligibility process flow
can be examined in all
details in one place
Debug decision services
including all rules and
expressions
Step-by-step processing
Change data object values
Set break points and watch
points
See intermediate results/state
of data objects
© 2013 SAP AG. All rights reserved. 11
Test Case Administration
All test cases for a comprehensive
regression test can be stored via SAP
NetWeaver Decision Service Management
and run on a regular basis for consistency
checks
■ Test case: Test data and expected results
■ Mass processing of test cases
■ Analyze test runs and
compare actual results
with expected results
■ Test case execution
history
© 2013 SAP AG. All rights reserved. 12
Key Take Aways
2. Respond rapidly to changing business requirements – by adapting
decision-making logic used within SAP for Insurance Claims
Management super fast
3. Decrease IT cost – by managing business rules at a central place and
re-use them where needed (no more duplication of rules!)
By using SAP NetWeaver Decision Service
Management in SAP for Insurance Claims
Management you can …
1. Increase the speed and quality of operational decisions – by
automating complex decisions via business-user maintained decision
services
Thank you
© 2013 SAP AG. All rights reserved.
© 2013 SAP AG. All rights reserved.
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