The Auto-Adjudication Threshold Conflict
A property-casualty insurer is replacing its claims platform. Of 220 requirements, a peer review flagged 38% as ambiguous or untestable and 14 as directly conflicting. The central conflict is auto-adjudication: claims operations wants a $2,500 threshold with post-payment audit, while underwriting and the special investigations unit want $1,000 with pre-payment review. State regulation requires acknowledgment of a claim within 10 business days and specific adverse-action notices. The vendor's rules engine can support different thresholds by jurisdiction, but the team has not documented those variations. Adjusters process 3,200 claims a day and 9% are reworked. The sponsor says to 'pick $2,500 and move on' because build starts in five weeks. Two of the 14 conflicts involve a regulatory notice. The business case assumed a 15% reduction in handling time.
1. How do you resolve the auto-adjudication threshold conflict without simply deferring to the sponsor?
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This is not a preference dispute; it is a business-rule decision with measurable risk trade-offs. My job is to make the trade-off visible and get an accountable owner to decide.
I would run a decision analysis with criteria agreed by both groups: fraud loss, handling cost, cycle time, regulatory exposure, and customer impact. Then quantify with data: 90 days of claims, loss distribution by amount and jurisdiction, fraud hit rate by threshold band, audit recovery rates, and rework rates. The likely finding is that a single global threshold is wrong; the rules engine's jurisdiction support suggests thresholds by claim type and jurisdiction.
I would facilitate a decision session with claims operations, underwriting, SIU, compliance, and the product owner, using the data and a decision table. The output is a documented rule with source, owner, effective date, and rationale, traceable to the 15% handling-time objective and the regulatory notice requirements. If the sponsor still directs $2,500, I would record the decision, the accepted risk, and the dissent in the decision log and escalate to the governance body if regulatory exposure exists. The BA does not win the argument; the BA prevents an undocumented guess from becoming a build instruction.
2. How would you address the 38% of requirements flagged as ambiguous or untestable?
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Treat it as a quality burn-down, not a rewrite-everything exercise. Thirty-eight percent of 220 is roughly 84 requirements; rewriting all of them in five weeks alongside build is not credible.
First, define the quality criteria the review will use: clear, complete, consistent, feasible, testable, and traceable. Then triage the 84 by risk and build dependency. Regulatory, financial, and Release 1 requirements must be fixed before build; lower-risk items can be clarified during design if the owner and date are recorded.
Techniques: a shared glossary to remove terminology drift; acceptance criteria for every requirement; decision tables for rules like adjudication; use cases for adjuster workflow; structured walkthroughs with testers, because testers expose untestable wording fastest; and a prototype for the adverse-action notice. Set a definition of ready and enforce it at the gate.
I would track ambiguity burn-down weekly and report the count open, fixed, and accepted-with-date. The 14 conflicts get their own log, with the two regulatory conflicts escalated to legal review immediately. This keeps the effort proportional and gives the sponsor a truthful view of readiness rather than a single percentage.
3. What verification and validation approach would you use before sign-off?
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Separate the two questions. Verification asks whether we specified the right thing correctly; validation asks whether the business will accept it in use.
Verification: compliance and legal review each regulatory requirement against the clause it implements; peer review against the quality criteria; traceability from regulation to requirement to design to test; and test scenarios derived from requirements, not from design documents. A requirement that cannot produce a test scenario is not ready.
Validation: UAT with adjusters using realistic claim samples across jurisdictions and thresholds, including adverse-action notices; a pilot in one jurisdiction before statewide rollout; and acceptance criteria owned by the business, not by IT.
Because two conflicts involve a regulatory notice, legal sign-off is a gate, not a courtesy review. I would also prototype the notice and the adjuster override path, because those are the places where a technically correct rule produces a bad customer or compliance outcome. Sign-off should be based on evidence from these activities, not on a demo. I would document residual risks and any requirements accepted as-is with a date.