Dynamic case management using decision modeling | Part 2

by Jordy Voesten


The grey area

In the first part that I wrote a couple of weeks ago, I described the use of two kinds of decision in a dynamic case management solution: decisions defining the context of the case and decisions that use that context to define the flow of the case: next steps, case handlers, etc.

In this second part I will dive into some of the details behind the first type of decisions defining the context of a case and show you how you can define the “grey area”, where decisions are left to the knowledge worker handling the case. The outcome of the decisions defining context are then used to define case flow.

Determining claim coverage

Let’s go back to the insurance example.

When handling an insurance claim, one of the most important parts of a case is determining coverage and liability. For each of those, it is possible to determine an automatic answer for most of the cases, leaving a small number of cases that needs manual decisions.

In order to create this manual flow, the decision Determine Claim Coverage must have three possible outcomes: “Claim covered”, “Claim coverage denied” and “Claim possibly covered”. The (simplified) decision table could look like this.

A similar decision can be created for determining liability, also with three possible outcomes: “Client liable”, “Counterparty liable” or “Client possibly liable”.

Determining the case flow

The decision for determining the flow of the case can then use the coverage and liability outcomes to Determine Claim Next State. Part of this decision is shown here.

This decision setup makes it possible to open a claim, automatically determine coverage and liability and when both outcomes are positive go straight to determining damages, and when one of them is negative go straight to refusing the claim. When the automatic determination is unsure (possibly covered or possibly liable), the case stays in the corresponding determination state (determine coverage or determine liability) and a manual task is assigned to a claim handler.

Handling the grey areas

The combination of these two types of decisions gives you the opportunity to determine beforehand which cases you want to handle automatically (black or white outcomes for coverage and liability) and which cases you want a claim handler to take a look at (grey areas).

With time, these grey areas can be inspected to create new rules for making them either black or white, leading to more and more straight through case handling. However, just as important is putting the focus on the more difficult and motivating grey areas where we need our knowledge workers to add value, and differentiating your organisation from others.