Optimizing Claims Management for Greater Productivity

All healthcare payers try to attain the goal of rapid, first-pass claims processing. However, most organizations are forced to rely on large numbers of claims processors to manually adjust claims exceptions — which can account for 10-40% of their total claims volume. Typically, manually processing exceptions creates huge backlogs (or "inventory"), decreased processor productivity, increased paper routing, and mishandled claims. This execution gap can compromise compliance with service-level agreements, and that may result in substantial penalties or loss of business.  To compound the problem, the inevitable changes in claims rules may not be captured quickly enough to avoid additional problems.

Pegasystems' Claims Workstation+™ solution framework combines best claims-management practices with the power of SmartBPM® to improve the efficiency of core claims-processing systems and significantly reduce backlogs. It combines flexible work-queue design and real-time queue management with work automatically delivered to processors, according to each one's specific profile and skills.  It provides claims-management teams with real-time insight into claim inventory status — giving them the agility to respond to business changes quickly. In this way, Claims Workstation+ brings tremendous efficiencies and costs savings to payers' day-to-day claims operations.

Claims Workstation+ Benefits

• 40% increase in operator productivity within 3 weeks of deployment
• More than 40% reduction in claims inventory within 3 weeks of deployment
• 75% reductions in claims backlog within 1 month and 98% within 3 months of deployment with Pegasystems' automation of manual processes
• Elimination of paper routing and mishandled claims
• Reduction or elimination of overtime in claims departments
• Reduction in training time
• Improved productivity-measurement tools for operators
• Elimination of performance-based penalties

Claims Workstation+ Key Features

• Unified desktop
  • Integrates all the data needed by claims processors from back-end systems, including core imaging, claim-adjudication systems, and other data repositories (membership eligibility, provider information, claims history)
  • Provides custom views of data (portals) for examiners, managers, and system administrators
• Claim auto-fetch and display
  • Automates pre-fetch of work according to pre-defined queues, queue assignments to user profile, and work prioritization within individual queues
• Skill- and rules-based routing
  • Offers dynamic queue setup
  • Routes workloads according to your business rules and routing parameters (including line of business, claim types and subtypes, claim age, billed amount, provider types, specific error and codes, member and provider groups, and more)
  • Prioritizes claims to react to aggressive employer-group SLAs, providers with urgent requests, or other specific criteria based on your business rules
  • Facilitates processing specialization and/or cross-training as defined by your organizational needs
• Correspondence generation
  • Automates and personalizes correspondence generation for certain critical error and rejected claims, and claims requiring additional information
  • Includes templates for requesting additional member, provider, and medical information
  • Allows communication through multiple channels, such as e-mail, fax, and letters, using Microsoft Word formats
• Management controls and reporting
  • Provides individual or bulk claim transfers, dynamic queue generation, processor security, and work-queue maintenance
  • Measures throughput; individual and department productivity; compliance with regulatory, union, and employer-group SLAs; and provider-contracting requirements using an extensive suite of reports
  • Main menus offer operators online access to individual productivity information for the current day, and give managers online access to both individual and departmental productivity information.
• Rules-based architecture
  • Meets extreme business demands using J2EE-based architecture to ensure enterprise-class scalability
  • Ensures easy customization through a flexible development architecture
  • Offers a thin-client interface to give IT control of elements important to them and business users the flexibility to develop and change processes
  • Enables real-time integration by leveraging Pegasystems' extensive experience integrating with Q-Case/GTE, TPS/RTMS (EDS), Amisys, Facets, homegrown, and other applications