Add Value and Differentiate with Agile, Consumer-Focused Business Operations

The Challenge: Healthcare payers face a host of challenges as healthcare reform drives up costs, changes delivery models and squeezes profit margins while consumers expect more personalized service. Unfortunately, rigid legacy systems are ill suited to this shifting new world that demands an agile approach to managing business operations.

With Pega, flexibility and agility are guaranteed, enabling payers to successfully overcome the many challenges they face. Pega automates complex business functions with dynamic, intelligent processes that streamline front- to back-office operations, deliver personalized, member-focused service, ensure regulatory requirements are met and enable new products and services to be delivered at a faster pace. The eight largest U.S. healthcare payers covering nearly half of the nation’s population rely on Pega for one very good reason - Pega delivers results.

Learn more about Pega solutions for:

• Claims – Pega optimizes high-volume, high-cost claims processes from streamlining product configuration and benefits management to increasing first-pass rates by automatically repairing problematic claims.  Pega also increases claims operator productivity for finalizing pended claims, bringing end-to-end visibility and intelligent control to claims management organizations. View Claims Repair Solution and Claims Workstation+ Solution. 
• Customer Relationship Management (CRM) – Pega CRM makes it easy to provide consistent, personalized service by turning best practices into intent-led processes that tailor each interaction to the member or provider, situation, channel and care setting.
• Care Management –Pega’s care management capabilities enable healthcare payers to efficiently develop and manage high-touch programs for diverse populations, customizing and delivering individualized plans through a unified portal for utilization, disease and case management as well as health and wellness programs.
• Sales Process Management – With Pega, payers can rapidly design and implement compelling acquisition strategies for groups and individuals, facilitating best-practice sales, rating and underwriting processes while streamlining product selection and enrollment processing.
• Medicare/Medicaid – Pega’s intelligent automation drives efficiency, consistency and agility into the complex processes required to execute and manage Medicare and Medicaid programs, enabling error-free processing and immediate adjustment to changing regulations.
• ICD-10 – Pega facilitates accurate ICD-10 coding with intent-led processes that guide users through the steps for determining the right code. Combined with conversion tables, reverse mapping, translation rule creation and ICD reporting and modeling, Pega helps healthcare organizations rapidly complete successful conversions from ICD-9.

Customer Success
	Amerigroup Enhances Customer Care with an Integrated Desktop (case study) Pega is the power behind Amerigroups’s integrated desktop, which has eliminated the need to use multiple systems and automatically applies the appropriate regulations for Medicaid members and providers across eleven states.  In use by 700 customer care associates and nurses for member and provider services, authorizations, claims research and issue resolution, the Pega solution has delivered at 15% reduction in clinical average handle time and has doubled productivity in the claims unit. Amerigroup - Redefining Customer Centricity (podcast) Lynne Ecker, AVP, Technology Services and Leona Rickerson, Director, National Customer Care, at Amerigroup discuss how using Pega in the national contact centers for business processes like member and provider services, claims issue resolution and pre-certifications among other processes, has improved service and driven down costs. Customer must be king in the web world (Financial Times article) In the US, Amerigroup, a healthcare company, found its customer care centres were becoming bogged down by isolated systems and complex workflows that drove up operating costs, hampered growth and stopped the company from being able to deliver consistent service. Using Pega, average call handling time has been cut by 15 per cent, training time has been reduced and regulatory compliance has improved.
	Pegasystems Powers Medical Management Advancements at Smart Blues Health Plan (case study) A leading Blue Cross and Blue Shield Plan leveraged its success with Pega for claims processing to automate its medical management process. By streamlining authorizations, the Plan has significantly cut response times while achieving 100% authorization accuracy.