A leading Blue Cross and Blue Shield Plan leveraged its success with Pega business process management (BPM) for claims processing to automate medical management. By streamlining authorizations through guided data collection, intelligent data presentation and automated activities, the Plan has significantly cut response times while achieving 100 percent authorization accuracy as well as improving consistency and compliance.

Business Issue

Medical management processes were highly manual, fragmented and inefficient, resulting in steep costs, suboptimal health outcomes and impaired customer service that affected the Plan’s ability to hold down premium prices.

Solution

Pega BPM and Healthcare Solution Frameworks have fully automated the Plan’s medical management processes for prior authorizations and pre-certification, reducing costs and improving the quality of service.