Case Study

OptumRx safeguards health and eliminates waste

"Some of the metrics as far as turnaround time [have been] drastically reduced. We've gone from days to minutes."

The Business Issue

One of the largest pharmacy benefit management companies in the U.S., OptumRx (formerly Catamaran) was forced to reevaluate its IT systems because of a new Center for Medicare and Medicaid Services mandate. The mandate called for OptumRx to eliminate fraud, waste and abuse and safeguard member health.

The Solution

OptumRx used Pega's Healthcare Industry Foundation on Pega Cloud to deliver a suspicious case-handling system for pharmaceutical claims for both Commercial and Medicare Part D members.

The Results

In less than four months, the new system was up and running, delivering these results:

  • Decreased turnaround time
  • Easier auditability
  • Decreased manual touchpoints
  • Improved scalability, efficiency and accuracy

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  • Industry: Healthcare & Life Sciences
  • Product Area: Platform
  • Challenge: Operational Excellence