Pega for Healthcare

Personalizing engagement for better health outcomes.

Personalize Engagement

Healthcare heart meets retail responsiveness

Today’s members expect you to be as responsive and personalized as their favorite retail brands. They need you to know not only about their administrative issues, but their health and financial concerns, too. And they expect you to add value to their healthcare journeys, every step of the way.

Seems like a lot, right? Not if you combine real-time data, AI technology, and an integrated healthcare CRM stack that delivers relevant, high-value information along with personalized offers and valuable assistance.

Nothing is more personal than health – and when talking to members, you can’t afford to make mistakes. Pega empowers you see the whole picture, exceed expectations, and have the right conversation every time.

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Build for Change: Next Best Action

Maximize the customer’s value to the organization with Pega's Next Best Action.

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Case Study

Anthem’s Secret for Next-Generation Service

Intelligently centralizing data so that each customer service call is contextual and exceptional.

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Provide Peerless Service

Superior service. Everywhere. Every channel.

Be honest: Is your service reactive or proactive? Are you going the extra mile to deliver seamless, flexible, and intuitive experiences – or are your members still working their way through the same old interactive voice response?

With Pega, you can create consistently amazing experiences everywhere: on the web, on the phone, via chat, in an app. Our next-gen service application goes beyond a 360-degree view to deliver AI-driven insights that can be actioned in the moment, anywhere. And our unified healthcare automation engine streamlines and simplifies interactions, so you can provide personalized, concierge-style service across channels and devices. Now that’s taking the initiative.

Improve Health Outcomes

One-size care doesn't fit all

Knowing your members well can actually help them stay well. According to the National Institutes of Health, 60 percent of health outcomes are driven by non-clinical factors

To move the needle on improving health outcomes, your care managers need both a comprehensive, real-time understanding of each of your members and the tools to connect with them anywhere on their healthcare journeys. That doesn’t happen alone. It means tailoring care, personalizing engagement, and collaborating across care teams.

Pega Care Management delivers a unique combination of managed care best practices and real-time connected data. And our personalized care planning empowers teams and members to work together to reach the best possible health outcomes in any setting.

From better collaboration and coordination to better-quality care, Pega’s got you covered.

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Closing Gaps in Healthcare

Alere raised customer satisfaction (member & provider) and HEDIS scores by personalizing care gap notifications & activities.

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Pega Robotic Automation & Intelligence

Pega’s Robotic Automation and Workforce Intelligence suite delivers rapid value to organizations by automating manual tasks.

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Support Frontline Staff

Happy agents, healthy members

Your frontline agents are wasting time toggling between screens and applications. They don’t have access to up-to-date claims and benefits information. Oh, and they’re keeping members on the phone for too long. Together, all of this hurts the health of your business.

Pega Robotic Desktop Automation helps employees get more done, faster by simplifying, automating, and integrating the technologies and processes on their desktops. Our powerful automation streamlines sign-on, automates call wrap-up activity, and makes sure agents aren't stuck cutting and pasting the same information over and over in all of your disconnected legacy systems.

With Pega, you’ll cut operations costs, increase member satisfaction, and improve health outcomes, all while ensuring your front lines are always set up for success.

Simplify Complex Sales

Configure. Price. Quote. Close.

It’s hard to keep up when the rules keep changing. Just ask your sales teams. If they’re scrambling to find the latest eligibility and availability, they’re missing out on crucial opportunities

Meanwhile, your SFA system isn’t doing enough. Agents are stuck using disparate tools to select products and benefits, get their combinations rated, and generate quotes. Time spent on manual processes is time they aren’t prospecting, selling, or closing. If your reps and sales partners can’t easily find the right products and processes, how can you expect them to help members or group purchasers find the right coverage?

That’s why Pega intelligently guides users across your sales distribution channels through complex healthcare insurance choices, streamlining and automating the sales process from lead qualification to close. When you empower your sales teams with contextual insights, you can easily build the right proposals – and ramp up revenue.

PegaWorld Video | 3:01

Making the LINK for Customer Success at MGEN

Hear how MGEN tackled global enterprise transformation.

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Customer Success | 3:11

Delivering Results at Optum – Claims Adjudication Services

Optum realizes auto-adjudication lifts of 3 percent per year.

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Modernize Claims Automation

Agility for unpredictability

Agility and flexibility are critical in today’s unpredictable regulatory environment. Legacy claims systems are often clunky and not up to the task of supporting reform mandates, increasingly complex risk-sharing agreements, and incentivized health management strategies. Isn’t it time to bring claims management into the digital age?

Pega’s modular approach to processing and superior business rules capability improve claim accuracy and real-time processing, no matter how complex things get. Our low-code solutions mean you can course-correct quickly as changes occur. And our automation boosts first pass rates, reduces manual touches, and yields unprecedented levels of administrative efficiency.

Improved auto-adjudication, reduced fees and fines, and improved cash flow. That’s Pega policy.

Drive Operational Excellence

Real automation. Real results.

Yes, your legacy systems are full of valuable data – but if they’re not fast or agile enough to handle today’s claims volume, they’re only holding you back.

The good news? You can get nimbler and smarter without ripping everything out and starting again. Pega’s wrap-and-renew approach preserves stability while adding agility, so you can work at the speed you want while still keeping the rich data you need.

Pega is the industry’s only unified digital process automation platform, with robotics, process automation, and case management together in a unified architecture. We build in powerful decision analytics, so you’ve got everything you need to automate any process in your business. With Pega, you start with the outcome you want to deliver, then bring your legacy systems and digital channels together to get results.

Healthcare Summit 2016 | 49:31

Florida Blue's Journey

Hear how Florida Blue is using Pega Robotic Automation to discover, manage, and automate work across all of its claims operations.

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Video | 24:05

The Compliance Advantage in Medicare Advantage

In leveraging Pega’s healthcare automation to prove Appeals & Grievances compliance, this payer also gained double digit savings and grew revenue by $50 pmpm – all while growing its membership by nearly 70%.

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Benefit from Compliance

Turn compliance into a competitive advantage

There’s a lot at stake in your compliance activities – and we’re not just talking about member satisfaction and protection from fines. Non-compliance can impede access to care, reduce the length of your open enrollment seasons, and directly affect your premium revenue.

Fortunately, Pega’s healthcare automation software makes compliance easy. Our smart technology guides processes through regulatory steps, the system sends correspondence as and when required, and your cases are resolved within the right timeframes. Plus, sharing information for regulatory audits is as simple as pushing a button.

That five-star rating isn’t as far off as you think. Let Pega show you how to get there.

Streamline Provider Management

You can’t solve today’s problems with yesterday’s data

Your provider network is essential for your business, but it’s constantly in flux. Physicians move or change hospital affiliations. Contracts are renegotiated. New payment terms are introduced. And if your physician and facility data is old or inaccurate, you not only risk lowering provider satisfaction – you could also drive up claims costs, complicate member enrollment, and even disrupt care.

With Pega’s healthcare automation technology, handling constant change is a no-brainer. You can orchestrate provider management and streamline back-office processes: credentialing, contracting, and even day-to-day demographic changes for both physicians and facilities. Improved speed and accuracy keeps provider data fresh and minimizes collateral damage. Consider it the cure for your provider management headaches.

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United Concordia’s Credentialing & Site Audit Solution

UCD had quick success, streamlining back-office Provider Credentialing processes in less than four months.

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Personalizing engagement for better health outcomes.

Explore featured applications and solutions for healthcare payers:

Customer Service for Healthcare

Engage across the healthcare continuum.

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Sales Automation for Healthcare

Convert more prospects to customers.

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Pega Care Management

Collaborate and coordinate for improved outcomes.

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Pega Healthcare Claims Automation

Resolve, simplify, and deliver.

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Get Pega for Healthcare Payers

Let us show you how Pega can help your business.