Perfect and Automate Medicare and Medicaid Services

The Challenge. Healthcare organizations face a tsunami of increased volume and costs with millions of people joining the Medicare and Medicaid ranks in the coming years. These organizations need highly efficient processes and the ability to respond rapidly to changing regulations in order to deliver cost-efficient, consumer-focused services.

From sales and enrollment to service, prior-authorizations and MTM management, Pega offers comprehensive solutions for managing government-administered healthcare programs including Medicare Advantage, Medicare Part D, Medicaid, MMIS, Tricare, FEP, CMS star ratings and more. Pega unifies flexible business rules with intelligent processes to dynamically manage complex interactions from start to finish, automate common and repetitive tasks and immediately adjust processes to account for changing regulations. With Pega, health plans, providers and PBMs can achieve the level of efficiency and accountability needed to fully comply with government requirements while delivering a higher standard of personalized care.

• Cut enrollment time and costs. Seamless integration between sales and application processes combined with automated guidance, materials fulfillment and status updates streamline on-boarding for self-service consumers, agents and call center representatives.
• Manage complex cases throughout their lifecycle. Holistic case management provides a 360-degree view that offers real-time visibility into the patient and each related case across multiple organizations, departments, users and processes.
• Substantially reduce costs. End-to-end process automation orchestrates all of the people, processes, channels and systems required to complete complex tasks.
• Increase compliance. Flexible, rules-driven processes ensure adherence to regulations, while automating the application of specialized requirements.
• Enhance productivity. Intent-led processes guide users through each step, increasing efficiency while ensuring the consistency of decisions.

Customer Success
	Amerigroup Enhances Customer Care with an Integrated Desktop 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 a 15% reduction in clinical average handle time and has doubled productivity in the claims unit.
	Capturing a New Market in Record Time Deployed in under 90 days, this Pega solution provides the platform that has allowed the Prescription Drug Plan provided by CSC to grow its Medicare Part-D business from $0 to $1 billion in less than a year. The organization has increased enrollment to over a million members while significantly reducing staffing levels, average call times and training costs.
	Security, Compliance and Automation in Less Than Two Months at VIPS View this PegaWORLD presentation to learn how VIPS used Pega for their Medicare Part D deployment at CMS. The presentation examines the selection, deployment and results of using Pega’s Customer Process Manager for Healthcare to manage the CMS retiree drug subsidy business across multiple communication channels, including Web self-service.