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Case Study

Molina Healthcare transforms appeals and grievances

  • Developed new application for appeals and grievance processes
  • Reduced time spent on data entry
  • Increased speed of case resolution

“After starting our transformation to Pega, we now have 7,000 active users, using three tier-one platforms that were built and deployed in Pega. We are also consolidating different business processes and workflows into Pega to bring [users a] seamless experience by enabling integration between different applications that we use here today.”

The Business Issue

Molina Healthcare is a Fortune 200 company that provides Medicaid, Medicare, and marketplace health insurance coverage to more than 4.5 million individuals across 19 U.S. states. As membership has grown over the years, it has become critical that Molina transition away from homegrown applications to a scalable, sustainable platform to meet business needs.

Specifically in the appeals and grievances processes, there was room for improvement. The existing in-house application was dated, inefficient, and not scalable. It lacked standardization – with each health plan following their own processes – making it difficult for Molina to integrate with other systems in its portfolio.

These technical issues led to business problems, including overturned appeals, duplicate denials, and thousands of hours spent on manual data entry. Molina saw an opportunity for process improvement and automation, better correspondence with members, and integration with core systems.

The Solution

With consultation from Cognizant, Molina completed a thorough structured analysis on market-leading products, and ultimately chose Pega for its platform transformation. This decision was based on Pega’s ability to scale fast, and our low-code workflow development and flexible integration. The ability to host Pega on Azure was an additional positive point for the Molina team.

The Results

After piloting the new platform with two of its health plans, Molina began to onboard additional health plans every two months. So far, the company has seen the following benefits:

  • $3 million saved annually
  • 30% reduction in case resolution time
  • 60,000 hours per year saved from automation of outbound correspondence
  • New plan onboarding time reduced to weeks from months
  • Standardized workflows across all health plans while retaining the agility to accommodate geographic and contractual variations
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Industry: Healthcare Product Area: Platform
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