P&C Claims Exception Orchestration
Orchestrate Complex Claims Workflows Without Replacing Your Core System
Eliminate manual handoffs, unmonitored email chains, and late referrals across high-severity P&C claims. We build governed orchestration layers using IBM Business Automation Workflow (BAW), Operational Decision Manager (ODM), and watsonx around your existing core platform (Guidewire, Duck Creek, or legacy AS/400) — delivered in fixed 2-week sprints.
Where Complex Claims Stall in Midsize & Regional P&C Carriers
With commercial auto liability claim severity surging 78% and social inflation driving up litigation costs, manual coordination across complex claims creates serious combined ratio exposure:
1. The “Waiting Room” Problem
Complex claims involving severe bodily injury, legal representation, or high reserves sit in email inboxes or custom spreadsheets, waiting days for medical review, SIU triage, or supervisor authority sign-off.
2. The Core Replacement Trap
Attempting to fix workflow friction by ripping and replacing the core claims engine requires 3–5 years and tens of millions of dollars. Operations cannot wait years for simple triage rules and handoffs to improve.
3. Fragmented Audit Trails
Critical settlement approvals and coverage evaluations occur informally in side communications outside the core system, exposing the carrier to bad-faith litigation and regulatory compliance findings.
Governed Exception Orchestration for P&C Operations
We modernize around your existing systems, connecting human adjusters, rules, documents, and core databases:
1. Dynamic Referral & Escalation Workflows
We deploy IBM Business Automation Workflow (BAW) to automatically route claims requiring specialist intervention (litigation, severe injury, fraud indicators) with clear ownership, SLA timers, and automated escalations.
- Single unified task inbox for adjusters, supervisors, attorneys, and medical reviewers.
- Automated deadline tracking with proactive alerts before SLA breaches occur.
- Complete chronological activity history written directly back to the core claims file.
2. Business Rule Governance (IBM ODM)
We centralize financial authority limits, policy coverage logic, and state-specific regulatory compliance rules in IBM Operational Decision Manager (ODM), empowering claims operations to adjust rules without IT code deployments.
- Version-controlled, auditable decision tables for reserve thresholds and settlement authority.
- Instant policy rule updates across commercial auto, general liability, and workers’ comp.
- Deterministic execution guaranteeing 100% adherence to carrier guidelines.
3. Non-Invasive Core & Document Integration
We connect the orchestration layer to your core claims systems (Guidewire ClaimCenter, Duck Creek, or legacy AS/400) and document repositories (FileNet, SharePoint, OnBase) using IBM App Connect and modern REST APIs.
- Bi-directional synchronization preserving the core system as the financial source of truth.
- Automated packet compilation pulling police reports, medical bills, and photos into one view.
- Zero disruptive re-platforming required for underlying core database engines.
4. Human-in-the-Loop watsonx AI Assistance
We integrate IBM watsonx AI models to ingest, classify, and summarize lengthy medical records, demand letters, and legal briefs — serving synthesized summaries to adjusters while keeping critical decisions human-controlled.
- Automated extraction of injury codes, treatment timelines, and demanded damages.
- Anomaly detection flagging inconsistent billing or duplicate medical charges.
- Strict human approval gates for any action affecting coverage, liability, or payment.
Running Core Claims Records on IBM iSeries / AS400 or Mainframe?
Explore our Mainframe Integration practice for non-invasive Change Data Capture (CDC) and sub-second Kafka event streaming.
Multi-Year Core Replacement vs. Multishoring Workflow Orchestration
Why midsize P&C carriers choose workflow modernization over risky platform overhauls:
| Dimension | Full Core Claims Replacement | Multishoring Workflow Pods Pragmatic Modernization |
|---|---|---|
| Time to First Value |
✕ 24–48 Months
Multi-year wait before first business line goes live, during which adjusters continue operating in manual, broken handoffs.
|
✓ 8–12 Weeks Production Pilot
Focuses on one high-friction process (e.g., commercial auto injury referral), delivering measurable cycle time reduction in weeks.
|
| Implementation Risk |
✕ High Operational Disruption
Massive data migration, legacy database freezes, and steep learning curves that disrupt everyday adjuster productivity.
|
✓ Zero Core Disruption
Wraps non-invasive orchestration and API contracts around existing core systems without touching stable transactional ledgers.
|
| Decision Accountability |
✕ Rigid Black-Box Workflows
Hardcoded core rules requiring vendor change orders for minor adjustments to referral thresholds or authority bands.
|
✓ Governed ODM & Human Control
Business-managed decision tables in IBM ODM with complete audit trails and mandatory human approval on financial decisions.
|
| Engagement Model |
✕ Heavy Advisory Armies
Large generalist teams with high overhead, disconnected from day-to-day claims operations realities.
|
✓ 2-Week Agile Sprints
Dedicated senior automation engineers in Poland working directly with your claims leadership with 4–5h daily US live overlap.
|
Start with the 10-Day Claims Workflow Friction Assessment
A focused evaluation of one critical claims referral process to quantify delay bottlenecks, map system handoffs, and design a fixed-scope orchestration pilot.
Process & Handoff Mapping
Reconstruct current referral paths, document flows, authority sign-offs, and communication gaps between adjusters and specialists.
Wait-Time & Friction Audit
Measure cycle delays, unmonitored queues, rework rates, and missing document triggers using your historical claims data.
Target Orchestration Architecture
Design IBM BAW task topologies, ODM decision tables, core system API contracts, and watsonx summarization touchpoints.
Executive Pilot Roadmap
Deliver fixed-scope 8–12 week pilot proposal with defined ROI projections and SLA improvement benchmarks.
“In high-severity P&C claims, every day of unassigned wait time increases legal exposure. By automating task handoffs and decision rules around existing systems, carriers resolve complex claims faster without taking on the multi-year risk of core replacement.”
Justyna
PMO Manager & Engagement Lead, Multishoring
Frequently Asked Questions: P&C Claims Exception Orchestration
Do we need to replace or modify our core claims system (Guidewire, Duck Creek, AS/400)?
No. Our architectural principle is to modernize the workflow around the core, not replace it. Your core claims platform remains the authoritative financial system of record. We integrate via standard REST APIs, webhooks, or messaging queues to trigger external review workflows and write back approved settlement decisions and notes.
Which insurance lines of business benefit most from workflow orchestration?
Our solutions deliver the highest ROI in complex, high-severity lines with multi-stakeholder reviews, including Commercial Auto (bodily injury & litigation), Workers’ Compensation (medical management & return-to-work), General Liability, and Commercial Property catastrophe claims.
How does IBM Operational Decision Manager (ODM) handle carrier authority limits?
IBM ODM provides central, business-readable decision tables that define financial thresholds, supervisory sign-offs, and state-specific compliance rules. Claims operations teams can adjust authority limits or add new triage rules in minutes through a governed interface without requiring IT code deployments.
How do you ensure AI remains governed and does not make unauthorized settlement decisions?
We strictly implement a ‘Human-in-the-Loop’ architecture. IBM watsonx AI agents assist adjusters by summarizing lengthy medical transcripts, extracting demand amounts, and highlighting policy exceptions. However, all critical actions affecting liability, reserve changes, coverage denial, and payment approvals require explicit human adjuster confirmation.
What are the primary deliverables of the 10-Day Friction Assessment?
Over 10 business days, our senior workflow architects deliver a detailed map of current handoffs and wait times for one selected claims process, an IBM BAW / ODM target reference architecture, a quantified business case based on your historical data, and a fixed-scope 8–12 week pilot roadmap.
How does your nearshore engineering team collaborate with US claims and IT operations?
Our senior automation engineers in Poland operate with 4–5 hours of daily live overlap with US Eastern and Central business hours. We run agile 2-week sprints with joint reviews, transparent Jira/Slack communication, and complete documentation for internal handoff.
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