In the insurance industry, claims review organizations are responsible for processing high volumes of medical bills, applying regulatory rules, and negotiating discounts across multiple payors and provider networks. These processes are complex, data-intensive, and prone to inefficiency when managed through outdated systems. To remain competitive, insurers and claims administrators require scalable automation platforms that can execute large rule sets, adapt to policy changes, and ensure compliance across jurisdictions.
Challenge
Before Decisions, the company relied on a legacy rules engine that was being sunset. The system struggled with:
- High operational overhead for maintaining thousands of rules across customers.
- Slow cycle times for implementing rule updates or changes.
- Scalability limits, especially when processing thousands of bills simultaneously.
- Manual interventions, including editing bills and rerouting documents.
- Format complexity, with claims arriving in varied file types (PDFs, XML, flat files).
These issues drove the need for a modern automation platform that could handle parallel processing, integrate with existing workflows, and simplify ongoing rules management.
Solution
The company implemented Decisions as the central rules engine for its Explanation of Review (EOR) process. Key capabilities included:
- Rule-driven document routing, automatically directing bills based on allowance thresholds, customer-specific policies, and regulatory requirements.
- PPO network determination, applying routing logic to evaluate which provider network rules applied based on customer, line of business, and services rendered.