Industry Solutions

Pegasystems’ industry-leading SmartBPM® suite provides private and government healthcare organizations with applications for core functions.

 

Solutions In Action

Rapid Deployment for Member Surge	Personalized and Responsive Service	Claims Processing Automated	Safety, Compliance, and Automation
New Value Comes to Old Systems	Personalized and Responsive Service	Average Handling Time Cut by 26%	Paperless System and CMS Compliance
Real-Time System Boosts CRM	Automation and Call Centers	Prescriptions Automated and Streamlined	Automated Claims Processing
Quick Solution Captures New Customers	CRM Grows to 98% Customer Satisfaction	100% Straight Through Processing	Benefit Coding Compliance

Today, healthcare payers are faced with numerous and competing business drivers. A shift towards consumer focus, driven largely by the advent of e-Health and members’ increased use of the Web, has caused many organizations to reassess their processes. The result is a move to an integrated, customer-centric contact center model to better serve constituents across multiple channels of interaction.

While continuing to focus on controlling costs and increasing service utilization rates, most organizations view access and consistency of healthcare information as a critical factor in achieving success. To be successful and maintain a competitive edge, healthcare organizations must optimize their business processes to collect, package, and use their critical data across the enterprise.  Adding to the complexity is the fact that this must all be done while simultaneously ensuring synergy and end-to-end integration with their back-office legacy systems and databases.

Pegasystems’ industry-leading SmartBPM® suite, based on patented Build for Change® technology, provides private and government healthcare organizations with applications for core functions.  These functions include: claims, customer services, acquisition, retention, and other decision intensive areas.  SmartBPM helps these companies automate and optimize complex interactions, processes, and resources across the enterprise for measurable administrative savings, improved productivity, and increased service quality.

SmartBPM addresses needs across New Business (enrolment, product changes, sales process, and tailored offerings), Customer Relationship Management (CSR & 360-degree views, claims management, and web self-service), Servicing Backbone (case & event management, payer/provider collaboration, and exceptions management), and Risk, Fraud, & Compliance (HIPAA and other regulatory compliance, recovery & subrogation, and medical/disease management).

Pegasystems gives organizations a superior head start with its Healthcare industry frameworks, including the Payer Industry Framework, Claims Automation Suite, Sales Process Manager Solution Framework, and Customer Process Manager for Providers & Members. Pegasystems provides the best of build vs. buy – extensive, upgradeable pre-packaged best practice Solution Frameworks plus powerful tools that enable rapid configuration to meet customers’ unique needs.