Healthcare payer organizations face a unique combination of complex challenges, from increasing competition to changing industry practices to the complexities of administering member benefits.  They need to offer new products, protect and grow membership, improve operating efficiency, increase partner collaboration, and ensure regulatory compliance. Increasingly, healthcare payers turn to information technology to find new ways of managing complex change.  Pegasystems' rules-driven Business Process Management (BPM) solutions rapidly deliver agility and flexibility to organizations, allowing them to exceed management goals and quality expectations.

Built on Pegasystems' award-winning SmartBPM® platform, the Healthcare Payer Industry Framework™ provides payers with the foundation for rapidly deploying solutions across their organizations. The Framework delivers core, reusable elements to automate and optimize key business processes such as billing, enrollment, provider contracting, new product development, and authorization management. It provides payer organizations foundational elements to quickly build both customer-facing and internal applications that extend the capabilities of their existing systems, maximize human performance, and exploit new market opportunities in a fraction of the time required with traditional development environments. With the Framework, Pegasystems offers payers new opportunities for providing value to the healthcare ecosystem by driving growth, productivity and compliance.

Benefits

• Faster time to market — Reduce the time and cost to build SmartBPM applications by obtaining the common infrastructure needed for diverse healthcare solutions.
• Use of industry best practices — Build the most effective, optimally designed applications, based on Pegasystems' decades of healthcare experience.
• Buy and Build — Obtain the best of both worlds by using the pre-built foundational elements of the Industry Framework to build your own tailored applications.

Key Features

• HIPAA components — Pre-configured HIPAA-compliant data structures, properties, and methods that can be easily leveraged to create quick-win solutions. Sample HIPAA X12 intake and response transactions for claims, enrollment/maintenance, and service authorizations can be easily extended to other HIPAA transaction sets.
• Work templates — Case definitions and process flows, including an end-to-end template for managing healthcare authorizations. Straight-through processing of service requests is provided via pre-configured authorization rules. Service-level monitoring drives next-step processing, automated correspondence generation, work-party notification, and managerial verification.
• Data structures and properties — Pre-configured data structures, properties, and methods that can be used quickly and extended easily, covering a variety of work parties, infrastructure elements, and transaction types
• Solution-design models — Robust design models highlighting the use of reusable, service-oriented processing and decisioning objects, including organizational units, work parties, user portals and screens, and integration points