Determining Eligibility with Progress® Corticon®

Determining eligibility for thousands or even millions of people is a tremendous challenge facing organizations and departments across a variety of industries. The Progress® Corticon® Business Rules Management System (BRMS) is enabling these organizations to dramatically simplify the process by automating decision management to achieve greater agility, flexibility and control.

Products:

Corticon

SS_ Progress Corticon

Challenge

Across industries and departments, organizations make thousands of recurring decisions a day, many of which affect eligibility determination. Failure to manage these decisions effectively and accurately can result in fraud, risk or abuse; delayed benefits to citizens, customers and patients; and revenue loss.

Solution

The Progress® Corticon® Business Rules Management System enables organizations to automate the underlying rules that determine eligibility by separating business rules from application code.

Result

Progress Corticon delivers improved agility and faster time to value, freeing IT resources from traditional coding while empowering developers and business analysts to implement and modify rules outside the application, often slashing development and change cycles by as much as 90%.

Story

Challenge

Across industries such as insurance, banking, healthcare, government and e-commerce, organizations and departments make thousands of recurring decisions in the course of their daily operations. Many of these decisions affect eligibility determination for products and services like loans, government benefits, healthcare coverage, online purchases and credit approval, for example:

  • “Do we deny or approve the claim?”
  • “For which of our programs or products—if any—is the customer eligible?”
  • “If a person is eligible for one program, does it affect his or her eligibility status for another program?”
  • “What level of risk does this person pose to the organization? Based on that risk factor, what products - if any - should we offer?”

For many companies, the majority of these decisions are performed manually by people trained to follow rules via policies and guidelines. But with thousands of decisions being made each day, this method can be costly, time consuming, and often delivers inconsistent results. The consequences can be detrimental to both the business and the customer, resulting in:

  • Increased fraud, abuse or credit risk
  • Delayed access to eligibility benefits for deserving citizens, clients, or patients
  • Revenue loss or overpayments

In addition to the sheer volume of decisions being made, organizations – particularly within highly regulated industries - are also expected to quickly conform to constantly changing rules, policies and regulations. “We don’t often have much lead time to react to these changes,” explains Shirley Monroe, Chief Technology Officer - Human Services, Insurance and Aging, Commonwealth of Pennsylvania. “For example, our fiscal year ends at the end of this month, and the state has yet to pass a budget. We probably won’t see that for another three to four weeks, but we will be expected to respond to any required changes immediately.”

Some companies or departments have taken a more automated approach by hard coding business rules directly into their operational applications. However, because changes must be made to the underlying code by IT, most organizations struggle to keep up with the frequency and urgency of the changes that need to be made. “Our business rules were locked up in code,” says Julie Gross, Assistant VP of Business Systems Implementation at Unum – a Fortune 500 leader in disability, group life, long-term care and voluntary benefits. “Changes we needed urgently were taking 12-plus weeks to implement.”


Solution

There is a better way. Organizations around the world are using the Progress Corticon Business Rules Management System (BRMS) to streamline their approach to business rules management and improve the eligibility determination process.

Progress Corticon enables companies to make better decisions, faster by separating business rules from application code. It delivers improved agility and faster time to value, freeing IT resources from traditional coding while empowering developers and business analysts to implement and modify rules outside the application, often slashing development and change cycles by as much as 90%.

As a result, organizations are able to react far more quickly to changes in policies or regulations that could affect the eligibility process. “We add new rules to our system every day based on new studies, protocols, and regulations,” explains Carlos Bassi, CEO and Founder of Vitalbox “[Corticon] has significantly reduced our time to market because we can now develop and deploy a new rule within 10 minutes versus six hours.”

The agility to quickly react to change can prevent credit risk, fraud or loss of revenue due to an operational error. “With our old system we ran the risk of sending out incorrect benefit amounts…money in all likelihood we never got back,” explains James Weaver, Deputy Chief Information Officer – Human Services, Insurance and Aging, Commonwealth of Pennsylvania. “By automating this process with Progress Corticon we have improved program integrity and achieved cost avoidance.”

Most recurring decisions within these highly regulated industries are guided by complex rules with a number of interdependencies. The ability to manage that complexity at a high transaction volume is imperative to the eligibility process. “We have a quarterly Income Eligibility Verification (IEV) batch that must reconcile information across a number of sources…Corticon processed 2.6 million records in 43 minutes for a sustained throughput of over 1,000 decision sets per second,” says Monroe.

Business rules automation can greatly improve productivity, enabling organizations to better serve their customers, whether it is providing eligible citizens with the benefits they deserve, approving a customer for a loan, issuing an insurance policy, determining appropriate treatment or healthcare coverage for a patient, or approving an online purchase. 

Result

Government organizations are making great strides in automating systems to better serve the needs of millions of constituents and improve the agility and efficiency of public services.

However, legacy systems, constantly changing local and federal regulations, and complex policy can all affect an organization’s ability quickly and accurately deliver benefits to deserving citizens.

The Commonwealth of Pennsylvania Department of Human Services (DHS) is using Progress Corticon to automate the rules and logic behind the eligibility determination process within its integrated eligibility system. The department has already automated a number of actions, including non-modified adjusted gross income (MAGI) eligibility rules, and case actions. And by the end of the year it plans to automate the eligibility rules for Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and MAGI eligibility.

“The flexibility of Progress Corticon and the ability to translate rules into every-day language make it so much easier to use than other solutions or hard coding,” says Monroe. “Rules Management has become a more iterative and agile process with Corticon. What once took us weeks now takes days, if not hours.”

A number of other states have implemented Corticon as a cornerstone to their Health Information Exchange (HIX) and integrated eligibility systems; some receiving accolades and awards for their success. With Corticon, these state are ensuring they stay up to date with the latest eligibility rules, can maintain a record of what rules were in affect at any given time, and most importantly, ensure eligible citizens receive the benefits they are entitled to while reducing risk and fraud.

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