Notes From the Field: Pet Insurance Claim Automation Solution

Capture, Workflow, ECM and ERP: Recipe for Automation

I had a great call with one of our customers the other day, a major pet insurance organization.   Keeping on my theme from my previous post (Capture+BPM: Pre, Midstream, Post), I wanted to share some details.  They have built an amazing solution to automate their inbound claims process.  Here is the lay of the land, pre-solution:

  • They provide pet insurance for their clients
  • Clients file claims that include invoices from vets, etc
  • They receive 6,000-8,000 claims per week.
  • Before the solution, everything was manual, received by fax, email and inbound paper mail
  • Data was being entered manually into their ERP
  • Documents were being saved manually, one-by-one into their ECM system
  • They have stringent regulatory SLAs for claim turnaround and response
  • New regulations required detail down to the line items on invoices filed for claims
  • It was taking 60-70 business days once a claim was received to process

Ah, the pain of manual processing.  Here is the teaser, after implementing the solution, they are now down to a 20 day turn around, and believe through further tuning they can get to 7.  So, they have taken the time to process down to a third or their pre-solution burden, and create an overall electronic system for claims processing.

Claims Workflow Queue
Processors Now Have a Digital Queue

The solution has made the process remarkably efficient, taking us from 70 days down to 20 to process a claim.

The Solution Architect

So, here are the components of the solution:

Ephesoft (Capture)Ephesoft’s intelligent document capture solution is used to capture and classify claims from inbound fax, email and paper files.  Through its advanced learning engine, it auto-identifies the type of document, splits multi-invoice PDFs, and then extracts the invoice information down to the line item data.  The documents and XML are then passed to the workflow engine.

extract claim data
Ephesoft Classifies and Extracts Inbound Invoice Data

There is quite a bit more that happens within the front-end capture.   This organization has enabled review and validation where they can actually review questionable documents before they get passed to the workflow.  This prevents bad data and documents from entering, and allows a checkpoint for insuring a complete claim package.  Rejected claims are passed back to the customer, with a note about what is required to complete the claim.

insurance claims validation
Ephesoft Automated Validation and Rejection of Claims

Finally, they have also implemented capture through Ephesoft web services.  Through a web portal, the customer can upload claim documents, and they are passed via web service to the capture engine to be classified and have data extracted.

document capture and OCR web services
Web Page Front-end For Ephesoft Web Services

You can learn more about web services for OCR and document capture here:  Web Services for OCR, Capture, Classification and Data Extraction

BPLogix (Workflow) – The Ephesoft data package is ingested into the BPLogix workflow engine, and then presented to claims processors for review and extensive validation.  With the new regulatory requirement on-line item invoice detail, this is a critical step.

workflow for claims
The Workflow Engine Receives the Extracted Data

Microsoft Dynamics AX (ERP)– once all the data is verified and validated, all the claim data is placed into the ERP for final processing and payment.

capture to dynamics
Ephesoft Data in AX

Alfresco (ECM) – Once all is complete, the claim documents are placed into their end resting place, and can be accessed at a later date if an issue arises, or there is a need for further review.

alfresco
Alfresco is The End Resting Place 

Great use of multiple technologies to automate a painful business problem.  Shows off the true value of document capture within workflow to add another dimension of process efficiency.  What do you think?  Any success stories to share?  Please comment.

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