This chapter describes a scenario where IBM Production Imaging Edition is used to improve an existing business process. This scenario illustrates how the capabilities are applied in a realistic although simplified use case.

This chapter includes the following topics:

The fictitious company, Fictional Insurance Company A is a global insurance company, headquartered in the United States with satellite offices worldwide. Company A is looking to improve business processing and to streamline inefficiencies in its claim approval process. The current process is partially manual and time consuming. Although the company has strived to replace paper processes with automated electronic processes, portions of the process are still constrained by physical paper.

This scenario addresses aspects of the claims approval process. Specifically, it addresses how to streamline the submissions of documentation to the process by using document imaging including capture.

Company A seeks to improve their business process by streamlining inefficiencies in their claim approval process. The company is also concerned about increasing incidents of fraud and wants to find new ways to use the information that is currently locked inside of the documents.

Other issues have arisen. For example, it is difficult to find and group all of the documents that are associated with a policy holder and their open or closed claims. With a long and error-prone claim approval process, Company A faces unsatisfied clients, the potential of losing clients, and the risk of losing their market share.

Without a consolidated view of the activity of the client, the company is vulnerable to fraud. As fraud becomes an issue, the company wants to make the claim activity more transparent and get early indicators of potential fraud.

The top priority of Company A is to shorten the processing time for claims to improve client satisfaction. Documents need to reach the desk of the claim handler faster. Knowledge workers should be relieved from repetitious, clerical tasks. The process relies on printed documents and requires people in different locations to make decisions based on the content. Production Imaging Edition is the perfect solution to make the content available and to streamline the dependent business processes.

This section describes an extremely manual process. It outlines a worst-case scenario for the current process, illustrating all of the areas where improvement might lie. In your environment, you might have applied some improvements already in your process. Therefore, you might find this description less efficient than your current process.

Imagine that a client has a car accident. The car was severely damaged and towed to a repair shop. Fortunately, no one was injured. The client calls the local agent to report the accident and to make a claim. The client informs the agent that the car was towed to the repair shop.

The agent sends a standard form to the client to gather information about the incident. The client, named Jane, completes the form with information about herself, the policy, and the accident. She signs the form, enters the date on the form, and then sends the completed form by mail or fax to the agent. The agent checks the form for completeness and manually enters the claim information into the claims system. Then, the agent places the paper in an envelope and mails it to the Company A Claims Center.

The claim form is received in the mailroom of claims center, which receives tens of thousands of documents daily. The mail is logged, opened, date-stamped, sorted, counted, grouped, and placed in carts. The carts are rolled to the claims floor. The claim documents go to the filing clerk. The filing clerk takes each claim document, records it in the claim system, prints a folder label and attaches it to a file folder, and places the claim documents in the folder. The folders are put in a cart and distributed to inboxes on the desks of the claims handlers.

Periodically a filing clerk takes the folders from the out boxes. The good claims are taken to a filing clerk who files the document in a suspense folder in the claims center. The exceptions are taken to the exception desk for handling.

If a signature is missing, the clerk at the exception desk makes a copy of the claim form and places it in a window envelope and places the envelope in an out box for outgoing mail. The claims folders are placed in an out box for file folders that need to be filed.

Periodically a filing clerk takes the files from the out boxes. The claims folders are taken to a filing clerk who files them in a suspense file in the claims center. The mail is taken to the mailroom where, twice a day, the outgoing mail is sent through the postal system.

Meanwhile at a remote office, an agent checks if the repair shop, where the car has been towed, is authorized to perform repairs for Company A. Fortunately, this repair shop is authorized to perform repairs. The agent requests a written estimate from the repair shop.

The repair shop sends an estimate back to the agent by mail or fax. The local office mail clerk delivers mail and faxes to the desk of the agent. The agent goes through the mail several times a day and reviews and approves estimates. The agent checks the status of the claim online to see if the claims center has received the completed claim form. If the system shows that the form was received, the agent approves the repair on the system. The agent notifies the repair shop that the repair has been authorized and makes a copy of the estimate to keep on file. Once a day, the agent sends the original estimate documents to the claims center to be filed with the claim.

The claims system has a letter generation job that also sends a letter to the client, indicating that the claim is approved, and to the repair shop, indicating that it is authorized to begin repairs. Several days have passed since the client reported the incident.

The estimate from the repair shop is received in the claims center mailroom, sorted out, and placed in a cart that is rolled to the claims floor. The estimates go to the filing clerk who pulls out the claim file folder and adds the estimate to the folder. If the folder is missing (for example, pulled by a client service agent), a second folder is created to hold the estimate until the claim folder is returned to the file clerk. The estimate sits in the claim folder with the claim documents until the repair is completed.

After the car is repaired, the repair shop sends an invoice to Company A for payment. Two days pass before the claim center mailroom receives the invoice. The invoice document is received in the mailroom, sorted out, and placed in a cart that is rolled to the claims floor. The invoice goes to the filing clerk who pulls the claim file folder and adds the invoice to the folder. The filing clerk puts folders with invoices and estimates on a cart and delivers them to inboxes on the desks of the claims handlers. If there is no matching estimate, the file is taken to the exception desk with an exception routing slip.

The claims handler looks up the claim on the workstation and enters the invoice number, invoice date, and invoice total into the claims application. The claims system determines if the estimate and invoice match and if payment is authorized. If payment is not authorized, the clerk completes an exception routing slip, attaches it to the folder, and places it in an exception out box. The folders for good claims are placed in a separate out box for filing.

Periodically a filing clerk takes the competed documents from the out boxes. The good claims are returned to the suspense folder in the claims center. The exceptions are taken to the exception desk for handling.

Once a month, the completed claims are placed into boxes by claim number. The boxes are transported to the records center for long-term retention.

It is apparent that this process is long and involves many people who handle, transfer, match, and file the documents; who enter data; and so on. The goal with Production Imaging Edition is to eliminate as many of these tasks as possible so that the process is simpler and faster.

To improve the claim approval process, all the elements of a production imaging system are applied. This process captures documents and digitizes the paper form. Alternatively, the process can avoid paper altogether and use electronic forms when a physical copy is not needed.

Some documents still come from external parties or require signatures on the paper form. Therefore, Company A continues to use paper in these instances. The company receives the documents by scanning, fax, or email. It uses Optical Character Recognition (OCR), Intelligent Character Recognition (ICR), and Optical Mark Recognition (OMR) recognition to read data directly from the documents to eliminate manual typing of the data. The company stores the documents in the imaging system so that they are available online to anyone who is involved in the claims process.

The company uses workflow and process automation to streamline the process and eliminate manual sorting, routing, and filing steps.

Figure 4-1 illustrates the new claim approval process.

The new system can react to changing business requirements or modified infrastructure constraints quickly and efficiently. The architecture reuses existing components by orchestration.

This solution takes advantage of the following capabilities:

In the new process, the client can either call an agent or enter the incident online through the claims portal. In either case, electronic form records the client information.

A claim form is printed with barcodes to identify the form type and the policy data of the client. The client does not need to enter this data manually. The system mails the form to the client or sends it by email with a link to download and print the form. If clients file the form online, they can print the forms by themselves and sign them. Then they can return the signed form by fax or by email.

Figure 4-2 shows a sample of a printed claim form.

Meanwhile, the business process is initiated that handles the rest of the steps in the process. Alternatively, a case can be initiated with IBM Case Manager.

Regardless of the input channel, the process is the same. A capture workflow job is initiated to process the document. The capture system identifies the type of document and the specific incident by reading a barcode. The handwritten date is read using ICR. The system examines the area where the client signs the form. If it is blank, it is flagged for manual handling.

The claim form and any other attached documents are electronically filed in the imaging repository. Each document is identified with the incident number, policy number, and other key data that makes it easy to search and retrieve the documents. With the current solution, the document is available for viewing by every stakeholder in Company A without pulling a paper file or getting a copy.

The receipt of the form performs a second critical role. It triggers the claims process that was waiting for the document. The act of storing the document notifies any waiting processes that the document has arrived. This content is active. That is, the document is aware of related business processes and interacts directly with these processes. As a result, the claims process continues automatically when the document is received.

If an exception occurs, an automatic subprocess is initiated. For example, if the claim form was not signed by the client, a subprocess generates an email message or letter and sends it to the client asking the client to sign and resubmit the form.

Process automation can be applied to orchestrate the interaction with the agent, adjuster, and repair shop. For more information about this type of automation, explore the following resources for related scenarios:

Meanwhile, at a remote office, an agent checks whether the repair shop, where the car was towed, is authorized to perform repairs for Company A. In this scenario, this repair shop is authorized to perform repairs at contracted rates. The agent requests a written estimate from the repair shop.

The repair shop faxes an estimate to the fax server of Company A. The capture software imports any documents received by the fax server. The system recognizes that the document is an estimate, extracts key information, looks up the claim number, and matches the estimate to the claim.

Occasionally an unknown form is received. For example, a new repair shop might send an estimate in a new format for the first time. The document is manually identified by using the Click'n Key capability by a verification operator. After the form is identified, it is automatically handled the next time the company receives a similar estimate from this repair shop.

Figure 4-3 shows a sample of the estimate document.

Figure 4-4 shows two potential estimates documents, one of which has multiple pages.

The system can extract detailed line items from the estimate. In the past, this was too time-consuming and labor intensive. Now the system can do it electronically, and the additional data can be sent to a fraud defense process for statistical evaluation using analytics.

The estimate document is electronically filed in the imaging system with the claim form. The estimate data is updated in the claims system electronically.

The receipt of the estimate document also triggers the workflow to notify the agent. Through an online work portal or mobile application, the agent sees a notification in an electronic inbox. The agent approves the repair and notifies the repair shop that the repair has been authorized.

The claims system letter generation job is still used to send a letter to the client, indicating that the claim is approved, and to the repair shop, indicating that it is authorized to begin repairs.

After the car is repaired, the repair shop sends the invoice by fax to the central fax server. The capture software recognizes that the document is an invoice, extracts key information, looks up the claim number, and matches the claim to the estimate.

The invoice document is electronically filed in the imaging system with the estimate and claim form. The invoice data is updated in the claims system electronically, and the payment is generated.

Because the claim form, estimate, and invoice are filed electronically, the exceptions that once occurred when a document was missing are eliminated. The records are maintained electronically in the imaging system. Because the electronic records are accepted as authentic, paper documents are destroyed. The filing of boxes of paper in the records center is eliminated.

This claim approval process example showed that, with Production Imaging Edition, you can improve client satisfaction, accelerate the business process, and reduce costs. Processes are streamlined and become more efficient and more accurate. Documents are not lost or misfiled. Transparency is improved, allows for more accurate control of the information, and offers opportunities to reduce fraud.

The following tasks are among those tasks that are improved or eliminated:

Because the documents are entered into the system as they are received, every employee with appropriate access rights can view all relevant information anytime. You make better decisions faster because all the relevant information is available when they are needed. The system can reduce the clerical workload of the knowledge workers by automatically performing filing, routing, matching, and validation. Wherever possible, data entry is automated, and manual typing is eliminated. Data that was previously unavailable can be extracted and fed to analytics for improved decision making.

Chapter 5, “Designing a production imaging system” on page 139, explains how to design such a solution.