Claim Processing Segmentation by Customer History
Find Innovative SolutionsGenerate Solutions
Solution Overview
Problem
Existing systems for processing product claims do not automatically consider customer claim history or improve processing efficiency, nor do they provide information for supply chain management or reduce claim-related costs.
Innovation Solution
A method and system that process claims based on customer average values, determining if they exceed or fall below threshold values, and automatically handle claims accordingly, including further investigation and improvement plans for high-frequency claimants.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If automated processing is implemented for all claims, then processing efficiency is improved, but accuracy and reliability deteriorate due to inability to consider customer claim history
Solution Approach 1:
The system segments claim processing into multiple pathways based on customer claim history. High-frequency claimants (those exceeding a threshold number of claims) are routed to manual review processes, while low-frequency claimants are processed automatically. This segmentation allows automated processing to improve efficiency for suitable cases while maintaining human oversight for complex or problematic cases, thus resolving the contradiction between efficiency and accuracy.
2Reliability
If manual review is used for all claims, then accuracy is improved, but processing time and costs increase
Solution Approach 1:
Instead of applying manual review to all claims (excessive action), the system applies manual review only partially - specifically to high-frequency claimants who pose higher risk. The majority of claims from low-frequency claimants are processed automatically, reducing overall processing time and costs while maintaining sufficient accuracy through targeted manual intervention where most needed.
3Loss of energy
If automated processing is implemented, then processing costs are reduced, but ability to provide improvement plans deteriorates
Solution Approach 1:
The system implements feedback mechanisms that analyze claim patterns and generate actionable insights. When high-frequency claimants are identified through automated processing, the system provides feedback in the form of improvement plans and notifications to address underlying supply chain issues. This feedback loop ensures that automated cost-effective processing does not lose the ability to provide valuable improvement information, as the automated system itself generates and delivers this feedback.
Data Source
AI summary
A system and method are disclosed that provide for processing claims. The system and method include receiving a claim from a customer and determining if a customer average value associated with the customer is greater than or equal to a threshold value. The system and method also include processing the claim when the customer average value is less than the threshold value and determining if the claim meets one or more predetermined parameters when the customer average value is greater than or equal to the threshold value. In addition, the system and method include processing the claim when the claim meets the one or more predetermined parameters and forwarding the claim for further investigation when the claim fails to meet the one or more predetermined parameters and the customer average value is greater than or equal to the threshold value.