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June 26, 2006

Eligibility management - a perfect opportunity for business rules

One of the most common uses of decisioning technology in Government is the management of eligibility. As you will see this is mostly a rules and compliance issue, though there may be a role for analytics in deriving some of the rules. In an eligibility situation you are typically trying to make it easy to do several things:

These characteristics make it clear how business rules are an ideal technology. For example, a large retirement association has created an online site that will allow government employees to check their benefit status, explore other benefit opportunities, and submit requests. The application is for pension fund management and handles more than 100,000 members. All the domain knowledge for pension administration has been externalized from legacy code to business rules, allowing those who understand the rules tomanage them. These rules determine benefits eligibility, calculate benefits, and validate data allowing for members to self-serve with the transactions for which they are eligible.

Similarly a US State wanted to allow parents to determine online whether or not their children are eligible for state-sponsored healthcare benefits. The business rules power a health care benefits portal - users log on to the site and enter in specific information. Rules then analyze the user's entry to determine benefit eligibility and costs. This health care benefits portal is available online 24/7/365 making it easier for parents to find out what their eligibility is and to carry out relevant requests forpayment. The rules themselves are easily maintained by non-technical business people who understand the complex layers of regulation involved, ensuring that the portal stays up to date and accurate.

Although eligibility is a rules-based problem, descriptive analytics can sometimes be useful in deriving business rules for use. For instance, a regulation might require that a certain percentage of those applying be allowed a benefit and descriptive analytics could be used to determine a set of rules that would identity the top (or bottom) x percent. Descriptive analytics might also be used to consider the impact of the rules as more and more court rulings are insisting that rules can be biased if their effectis biased even if the rules themselves have no specific bias coded into them.

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Posted by James Taylor at 12:28 PM | Comments (0)

June 23, 2006

Podcast on business rules

http://edmblog.fairisaac.com/decisons_podcast/ has a new podcast on business rules. Enjoy.

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Posted by James Taylor at 4:33 PM | Comments (0) | TrackBack

Healthcare and credit-based decisioing

Saw this interesting little piece in Health Data Management today - Hospitals Should Know the Score. An interesting snippet on how important proper credit management is for hosptials - "As much as 30% of patient payments end up being written off as bad debt". How can an EDM ,approach help solve this? Well one of the most important measures providers can take to improve their financial condition is toensure they are billing appropriately for the healthcare services they provide—an effort that starts at the front door. During the admissions process, rules-driven applications can perform real-time validation of patient-supplied data against medical records and external data sources. By making certain patients are who they say they are and that addresses and other information are complete and correct, providers reduce their financial risk.

Prediction models and external data sources enable an EDM solution to predict, at admission or pre-registration, what the optimal initial payment request for patients based on their particular financial situation, what the optimal settlement amount is, and how to fashion a payment plan with the highest likelihood of completion. Guidance regarding the initial payment request increases revenue upfront and improves the effectiveness of intake staff. Knowing what patients can and will eventually pay enables financialcounselors to help patients who need help and minimize the number who go to collections, while also generating maximum revenue for the provider system. This is similar to a usual business approach except that you don't want to decline care because someone can't pay so much as help them pay for the care they need. Rules can also simplify and speed up admitting by guiding intake specialists through the most efficient process for each incoming patient.

Another part of the solution is to employ rules and models at the point of care ,to perform identity checks and likelihood to pay. Whenever a patient will incur an out-of-pocket responsibility above a pre-defined threshold (e.g., $25), an EDM solution can inform providers of an optimal strategy to maximize the likelihood of payment. The solution can also check the patient's information against all rules governing eligibility for charity care, Medicaid, and all types of supplemental funding. Rules would becreated and deployed consistently throughout the provider system to comply with both government and organizational patient payment policies, and can be monitored for compliance by staff throughout the organization. This prevents unecessary bad debt being accumulated during a patient's stay.

Once a patient is discharged, an EDM approach can also be used with overdue accounts to improve collection results and minimize recovery costs. Instead of treating all overdue accounts with the same sequence of dunning letters and calls, providers may, in fact, be able to collect more money by doing less. Analytics can identify differences between accounts that affect payment behavior—segmenting first-cycle delinquent accounts, for example, into those likely to self-correct, those likely to be influenced by collectionstreatments and those unlikely to pay under any circumstances. Providers can use this segmentation to save money by making fewer outbound contacts and thereby also reducing the volume of inbound inquiries such contacts generate. They can make an early referral to a collections agency of those accounts with very high nonpayment scores.
An analysis of delinquent accounts and collections work streams using an experimental design can enable a provider organization to determine which tactics are most effective for which types of accounts. An EDM solution can route accounts in collections to the work stream that will produce the most revenue in the shortest amount of time at the lowest cost.

By applying EDM to the problem of bad debt throughout the patient lifecycle, hosptials can collect more of what they are owed more quickly without having to turn away patients. Fair Isaac is developing an offering, Patient Decision Manager, to do just this and partnering with some leading hospitals to make it work.

Thanks to my colleague Larry Feinstein for help on this one.

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Posted by James Taylor at 11:35 AM | Comments (0)

June 22, 2006

Using business rules for Anti-Money Laundering

Interesting report by Henry Peyret of Forrester on A Business Rules Engine Decreases The Cost Of Fraud Detection. The system he describes is a classic use of a non-inferencing rules engine but I want to make a couple of points of clarification:

AML and other kinds of simple fraud detection are great for rules. Even if you have more complex fraud, requiring analytics, rules are still a crucial component in a solution.

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Posted by James Taylor at 9:33 AM | Comments (0)

June 21, 2006

Integrating Analytics into Business Processes

In The Four Styles of Integrating Analytics Into Business Processes ,Gareth Herschel and ,Betsy Burton of Gartner discuss the ,four kinds of analytic integration with business process – intra- or inter-application and explicit or implicit. Comparing this to my model of enterprise decision management it is clearthat I am talking about analytic integration with an implicit calling mechanism. For the kind of analytic integration I am discussing the inter-/intra- distinction is less important and can be considered a technical decision. Here's how they describe implicit invocation:

"Analysis that is implicitly called by the business application may be invisible to end users, constraining their choices or displaying relevant data as they follow the business activity."

This is how analytics are used in EDM applications – the analytics drive rules or decisions or are part of how a decision is made. They are typically not requested by a user. As far as the user is concerned they are requesting a decision, it is the design of the application that causes the analytic to be embedded. This is not to say that explicit embedding of analytic is not useful – far from it – it is just typically notwhat I mean when I talk about analytics in EDM.

So let's consider the two types that seem most relevant when thinking about EDM – these are what Gartner calls “Style 1: Intra-application and implicit” and “Style 3: Inter-application and Implicit” In both cases the analytic services are automatically performed without explicit user prompting but in the first case they are part of the primary application, in the second part of a different application (probably delivered through a service-oriented approach).

The key impacts of the various types are discussed in the paper so I will just make a couple of points that seem to be key for EDM:

Companies that have implemented a business rules platform to make decision automation easier will have no trouble adding analytic insight to those decisions using this implicit invocation approach. Companies trying to embed analytic insight into traditional code have only themselves to blame…

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Posted by James Taylor at 4:10 PM | Comments (0)

Don't be adversely selected against - use EDM!

I saw this article in National Underwriter - Data Use, An Edge For Some Insurers: Consultant. In this the authors of the study say

"Property-casualty companies that reject traditional business models in favor of the creative use of data mining and client segmentation will have an advantage in the coming years"

This reminded me of the discussions I have with insurance customers around being adversely selected against and how decision management, especially decision management that takes advantage of data mining and predictive analytics, can help. So what is "being adversely selected against" I hear you say. Well consider two companies, one has three prices (for good risks, moderate risks and bad risks respectively) and the other has nine (very good, somewhat good, slightly good, very moderate, somewhat moderate etc). This means that if a specific customer is in the good tier for company 1 they might be in any one of three tiers for company 2. Now company 2 is smart - they make their price for their "very good" segment better than company 1's "good" segment, their "somewhat good" segment price about the same and their "slightly good" price a little worse. Let's consider three potential customers:

Given this, customer A is more likely to pick company 2, customer B might go either way and customer C will likely pick company 1. Repeat over many customers and company 1 is likely to end up with more customers like C and fewer customers like A. Instead, therefore, of having customers spread evenly across the segment company 1 will have more customers at the low end of the range ("somewhat good") than at the high end ("very good"). This in turn means that the average customer for company 1 will be somewhere between "somewhat good" and "slightly good". In contrast, company 2 will get more "very good" customers and an average between "somewhat good" and "very good". For company 1 this means they are being adversely selected against - they have priced their segment based on the average but are getting people who average worse than that. If your competitors have more fine-grained pricing than you do, this is what happens. You end up with a customer portfolio that tends to be worse, on average, than you expect.

Segmentation1_1 Segmentation2_1

How do you avoid this? Well by more finely targeting and segmenting your customers. This takes analytics or data mining. If you can use your data to better predict risk and then combined this risk assessment with the rest of your data before segmenting your customers then you can get more fine grained segments. The two graphics show how more segments help you better match the reality of a continously changing risk curve. There's more on segmentation here and on the insurance industry and EDM here.

The key, as the study's author said, is to take informed risks.

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Posted by James Taylor at 9:55 AM | Comments (0)

Don't be adversely selected against - use EDM!

I saw this article in National Underwriter - Data Use, An Edge For Some Insurers: Consultant. In this the authors of the study say

"Property-casualty companies that reject traditional business models in favor of the creative use of data mining and client segmentation will have an advantage in the coming years"

This reminded me of the discussions I have with insurance customers around being adversely selected against and how decision management, especially decision management that takes advantage of data mining and predictive analytics, can help. So what is "being adversely selected against" I hear you say. Well consider two companies, one has three prices (for good risks, moderate risks and bad risks respectively) and the other has nine (very good, somewhat good, slightly good, very moderate, somewhat moderate etc). This means that if a specific customer is in the good tier for company 1 they might be in any one of three tiers for company 2. Now company 2 is smart - they make their price for their "very good" segment better than company 1's "good" segment, their "somewhat good" segment price about the same and their "slightly good" price a little worse. Let's consider three potential customers:

Given this, customer A is more likely to pick company 2, customer B might go either way and customer C will likely pick company 1. Repeat over many customers and company 1 is likely to end up with more customers like C and fewer customers like A. Instead, therefore, of having customers spread evenly across the segment company 1 will have more customers at the low end of the range ("somewhat good") than at the high end ("very good"). This in turn means that the average customer for company 1 will be somewhere between "somewhat good" and "slightly good". In contrast, company 2 will get more "very good" customers and an average between "somewhat good" and "very good". For company 1 this means they are being adversely selected against - they have priced their segment based on the average but are getting people who average worse than that. If your competitors have more fine-grained pricing than you do, this is what happens. You end up with a customer portfolio that tends to be worse, on average, than you expect.

Segmentation1_1 Segmentation2_1

How do you avoid this? Well by more finely targeting and segmenting your customers. This takes analytics or data mining. If you can use your data to better predict risk and then combined this risk assessment with the rest of your data before segmenting your customers then you can get more fine grained segments. The two graphics show how more segments help you better match the reality of a continously changing risk curve. There's more on segmentation here and on the insurance industry and EDM here.

The key, as the study's author said, is to take informed risks.

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Posted by James Taylor at 9:55 AM | Comments (0)

June 19, 2006

Top posts on BPM, SOA, CEP, BAM and business rules

Continuing the analysis and got this list is of ones related to business process, SOA, CEP and related topics. Here goes:

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Posted by James Taylor at 10:25 AM | Comments (0)

Top posts on business rules

I was doing some analysis the other day and identified your favorite posts and I thought it would be fun to show the list with some comments. The first list is of ones related to business rules. Here goes:

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Posted by James Taylor at 9:18 AM | Comments (0)

June 17, 2006

Top posts on going "beyond BI"

Last list of top posts. This list is of ones related to business intelligence. Here goes:

 ,

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Posted by James Taylor at 10:14 AM | Comments (0)

June 15, 2006

Insurers should collaborate to fight fraud - with data

Saw this article To Beat Fraud, Insurers Must Collaborate: NICB and it hit home. Collaboration is part of how the credit card industry drove down fraud. By pooling data on usage and fraud they were able to enable to building of sophisticated fraud models. These neural nets, combined with business rules in Fair Isaac's Falcon Fraud Manager product, delivered an EDM solution that had dramatic results.
Us_fraud_loss_chart2

I have blogged about the need for insurers to do the same before.

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Posted by James Taylor at 9:29 AM | Comments (0)

June 13, 2006

Customer Analysis when you have millions of customers

This interesting article on Customer Flashcards caught my eye yesterday. Chris and Zach do a nice job of presenting the idea of customer flashcards, combining lots of information into a single image, and how that might help you see more complex patterns and recreate a feel of customer intimacy (about which I have blogged before). I really liked theconcept and their examples were fascinating. What made me pause, though, was thinking about how to apply this kind of approach when I have hundreds, thousands or even hundreds of thousands of customers. Am I really going to scan that many flashcards? The discussion of Blink was also interesting but again made me wonder about applying this kind of "thin-slicing" (at which humans excel) to huge datasets (something at which humans do not excel).

So how could you apply this kind of approach to huge numbers of customers? It seems to me there are two ways:

Like all visualization techniques this has great potential for helping people make decisions. Equally, like all visualization techniques, it becomes challenging when your volume gets high enough to need decision automation so that, for instance, your website can do as good a job deciding as the people who can see the flashcards..

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Posted by James Taylor at 1:07 PM | Comments (0) | TrackBack

June 12, 2006

Book Review: The Real-Time Enterprise

This book was recommended to me by Mike Gonzalez over at Hands-on-BI. The book is a couple of years old but its time horizon was fairly long so it is still nicely relevant. The book introduces the concept of a Real Time Enterprise, discusses how exactly you can compete on time and talks about how various approaches, especially business process management, can and must be used as part of moving to an RTE. The book tries to avoid too much hype but sometimes falls victim to overblown rhetoric nevertheless.

There is a lot in the book about operational transformation, clearly a key ingredient in moving to an RTE, and the authors do a good job covering the people and culture issues as well as the technology ones. Some specific thoughts:

There is a great quote from Dr Michael Porter of HBS who , said "The essence of strategy is choosing to perform activities differently than rivals do". For me, the essence of strategy can be choosing to decide how to treat customers differently than rivals do. That takes EDM.

It's a readable book and a nice overview of some of the trends and responses in real time enterprises. There is more on the blog on several of these topics and the book can be purchased here.

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Posted by James Taylor at 4:22 PM | Comments (0)

Different approaches to adding insight to your decisions

I got an interesting comment ,the other day asking how to effectively conduct data mining in an EDM context - outsource or not? This made me think it would be worth posting a general description of the different ways to add analytic insight to a decisioning environment. Assuming we are talking about adding predictive analytic models to operational system (see this article for a discussion onpredictive analytics), there are several ways to bring analytic insight to bear on a decision.

  1. Find a score
    Clearly if there is an externally available score with a good reputation and relevance then use that. This is by far the cheapest and most effective - you don't need data or data mining/analytic expertise, just an understanding of your business and an ability to match it with a score. If, for instance, you are trying to manage credit risk then the FICO score or its global counterpart Global FICO is a great tool. These are typically available from bureaus (in the US) and sometimes have different names (BEACONand EMPIRICA are both FICO scores, for instance).
  2. Find a score that seems to be a good substitute
    If, as in most decisioning problems, you cannot find a score that works exactly consider if any of the ,scores that are available might be a good surrogate. Larry Rosenberger (Fair Isaac's head of R&,D) gave a great keynote on this at InterACT recently where he talked about the fact that many scores can predict unexpected things - for instance, your FICO score turns out to be a reasonably good predictor of whether you will stay fit or not.No-one is suggesting that there is a causal link here - having a good FICO Score does not MAKE you fit - but that some underlying characteristics (responsibility or ,integrity perhaps) mean you tend to act in ways both that drive up your FICO score and that increase your likelihood of fitness. You can thus analyze your customers by comparing behavior to available scores to see if any are a good (non-causal) predictor. A word of warning - don't ever rely on a single score, especially a singlescore for which you don't have causal linkage, to make a decision on its own. This will not work well and will get you in trouble with regulators (and quite rightly too).
  3. Work with a third party DSP
    There is growing interest in something called a Decision Service Provider or DSP. This involves basically outsourcing the decision-making piece of your process. You make the issue of finding the right data, working out where and how to get it and then decisioning with it someone else's problem. ,The DSP hosts the common and regulatory rules (helping you be compliant) ,and allows you to customize for your businesswhile handling the complexities of assembling a rich data set and analytics that use that data set. By and large this works best when there is lots of third party data that might make sense for you to include, e.g. about consumers, but where you don't have relationships with all the data providers.
  4. Have someone analyze your data and send you models (not reports)
    This is the classic way to get started. Work with someone like Fair Isaac who has the analytic/data mining skills to turn data into insight. You make your data available, though hopefully they have expertise too that will be brought to bear, and they help you by cleaning and arranging the data to make it usable to build predictions and then by building a predictive model from it. You want someone to hand over an actual model, or an analytically derived set of business rules, rather than a report that just tellsyou what you should do as it is important to keep the time delay between getting data and using that data to make better decisions to a minimum. Ideally you will use a package or build into your EDM framework a place to put the model so as to enhance your operational decisioing. You will likely also want to have the model refreshed on a timely basis (what is timely varies depending on the model).
  5. Have someone analyze the data AND teach you in the process
    You can take the approach in 4 and adjust it by having it done on-site with tools you can buy yourself. If you combine this with training and having your staff act as second-seat behind a qualified modeler you can build your own team and skills in parallel.This works great if you have a desire to staff up and do this yourself long term but want to get short term results.
  6. Buy tools and training and do it yourself
    There are good tools out there for doing the analysis and building models from it and even a few, like Fair Isaac's Model Builder, that will deploy the model for you into production systems. You can hire staff, train them and develop a unique brand of analytics for your decisions based on your customers.

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Posted by James Taylor at 2:16 PM | Comments (0)

Shifting performance management into action

I wrote this article for ebizQ on "Shifting Your CPM Into Action". EDM offers a platform for decisioning across processes that enables you to change the way your company works as your performance management infrastructure tells you that you should. Check out the various categories on this blog for more on these topics and don't forget my blog over on ebizQ - http://www.ebizq.net/blogs/decision_management.

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Posted by James Taylor at 1:29 PM | Comments (0)

Self-regulation and decision automation

I got an interesting comment the other day from Craig Cameron about the potential for self regulation - the fact that some businesses want not only to comply with government enforced regulations but also to "comply" with the wishes of socially conscious consumers, for instance. This got me thinking about how this might be the same or different from other kinds of ,compliance-oriented decision automation. Some thoughtsthen:

Thanks to Craig for an interesting line of thought.

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Posted by James Taylor at 12:07 PM | Comments (0)

June 9, 2006

Identity Theft - some stats and suggestions

I got a comment from the folks at Metrics 2.0 asking about stats on Identify Theft (something about which I have blogged a couple of times - here and here). I asked around and got some information. According to Javelin Strategy &, Research, Identity Theft affected about 9.3million people in 2004, causing $52.6 billion in losses in the U.S. alone. This was reported on in BusinessWeek. Since then Javelin has updated the report for 2005 and losses climbed to $56.6B (a fairly slow rate of climb). This compares with some $3 billion in losses for credit and debit cards combined for the US. The huge difference between these numbers has led some to criticize the Identity Fraud numbers but remember ,itdoes include things like mortgage fraud, utilities fraud, telecom fraud, auto loans, HELOC, etc. One identity theft can result in lots of losses across these different channels. That said I suspect the real identity fraud number is lower than $50B but still much higher than the credit/debit card losses.

So if you are worried about Identity Theft, and you probably should be, what can you do?

For companies

For individuals

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Posted by James Taylor at 3:56 PM | Comments (0)

June 8, 2006

Compliance, business process and business rules

I wrote a short article on the use of Business Process Management Systems (BPMS) and Business Rules Management Systems in compliance over at BPM Institute recently.

There's more on this blog on compliance and Business Process Management as well as some specific posts on why to keep them separate ,and on how to bring analytics into processes using rules.

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Posted by James Taylor at 9:17 AM | Comments (0)

June 6, 2006

CEP needs business rules too

I saw a comment on IT Analysis that talked about The difference between complex event processing and event stream processing. I liked the distinction drawn but have to take issue with the comment Philip makes agreeing with a CEP vendor about "why and where CEP works and BPM and rules engines don't. "

Its customer is an airport and its application is baggage handling...Clearly you could model this using a BPM process. However, what you would be modeling is a perfect day. ...—so the key to baggage handling is dealing with exceptions. Further, the exceptions are always different and have to be managed in real-time, which is why you need a CEP engine

Now I agree that this is why CEP complements BPM - the BPM engine handles the normal state and the CEP engine can handle exceptions. Where I disagree is in the idea that you don't need a business rules engine or a business rules management system. In fact I would go so far as to say that the fact that there is a case to be made for both BPMS and CEP is precisely why you do need a business rules management system!

Managing the events in real-time is clearly a specialty CEP capability. Deciding what to do about these exceptions is a business decision. The normal, day-to-day business process will also need some or all of those business decisions. Partner airlines or other external systems as well as other internal processes might want to use those decisions and decisions about routing baggage might depend on non-baggage related rules like those agreed in contracts with partner airlines on treating gold customers.

Keeping these business decisions in a business rules management system would allow them to be managed and re-used effectively across these different systems. Embedding them in the CEP system just means repeating them one more time. On top of which you add yet another place where you might want to start applying predictive analytics instead of just being able to analytically enhance the business rules environment and so benefit everyone.

Just because a product can handle business rules locally does not mean it should.

There's more on why BPMS and BRMS should be separate here and in Separating rules and process on Sandy Kemsley's ebizQ blog and much of the logic applies to CEP too.

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