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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