PegaWorld iNspire 2024: Virtusa Enables Healthfirst to Onboard and Manage Providers More Efficiently

Good afternoon, everyone. So, uh, it's a good crowd out here. Thank you very much for taking time to come to the session. So today we are here to share the story of, uh, healthfirst. How we have been able to work together towards a transformation on the provider side of the business. How do we really help in faster onboarding, managing the provider into the payer ecosystem? So today I'm joined with Ramesh. So Ramesh heads our, uh, provider business on the side of the business. And he has been a great partner whom we have been working for the last seven years.

We take pride on that relationship. I'm joined by Prashant. He has been into this healthcare industry for a significant time. And, uh, he manages the relationship for most of our PR accounts and myself. Alok Mandal I am the practice lead responsible for the consulting side of the business on healthcare and life sciences. So between the three of us, we carry close to 75 years of industry experience. We are deep rooted into healthcare. We would love to hear questions towards the end. And uh, excited to have you all today.

So with that, I'll turn it over to Ramesh. Thank you. Hello. Good afternoon. Thanks for joining us here. Um, quickly introduce myself and health first. And what we do. Um, I'm Shri Ramesh Shivani, based out of New York. Um, I've been with the health for the last five years.

Um, in this transformative journey that we did with Virtusa as well as the Pega in implementing that at Health First. Prior to that, I was with Anthem Blue Cross Blue Shield for almost 20 years. I led the provider transformation journey there as well. Um, so I'll quickly go through what we did to get the value out of this Pega as well as our relationship with Virtusa. So before that, I'll introduce our company healthwise, right? Um, HealthWise is one of the largest, um, nationwide not for profit health insurance company. Um, Healthfirst had a very unique business model, uh, working with, uh, you know, sponsored hospitals in New York City. Uh, we are catering to, uh, last 30 years. We are partnering with, you know, health systems in New York City, um, primarily in the New York City, as well as the five other neighboring counties.

We are primarily providing Medicare and Medicaid services and products as well. So kind of we are kind of providing that value based care. It truly value based care, because we are actually partnering with health system and our patients and providing that maximum value and care. Um, our this kind of unique relationship with the health systems helped us provide much more, better quality care to our customers as well as the members. Right. So our mission mainly, if you kind of think about vision and mission, we want to provide very, you know, qualified care, quality care to our customers, our members, and also accessibility to the care. Right. So increase the access to the care. So that's where we are kind of focusing on.

Um, and you know, we want to kind of provide every member of our, you know, health first in New York City to provide a much more, better care for them. So we are kind of working on different solutions to bring that value. And one of the transformation journey that we did from the on the provider side, I'll show you exactly how we are able to achieve that mission and vision. So just to kind of a few other points about health first. Um, it's a 15 of our New York City hospitals are our sponsors. Um, we have been kind of consistently, consistently achieving four of the five stars in our, uh, Medicare ratings. And we have more than 100,000 provider locations. We are continuing to grow as we are trying to expand more on different counties in the New York City. And we have almost reaching 2 million members in primarily in the New York City area, like primarily predominantly in the Medicaid space and also Medicaid space.

So it's a huge population for us, and it actually gives us much more need for why we need to improve our value based care system in the New York City. We have more than 5000 employees and constantly adding more employees as we go along to cater our members and as well as our providers. Right now, approximately reaching around $18 billion in revenue. And we are continuing to grow as we are providing a better value based care in New York City. So with that, I'll have Prashant quickly introduce Virtusa. Thank you, Ramesh, for the fantastic introduction to Healthfirst. I'm so glad ours is not the first session after lunch. This is the second session, right? I guess sometimes the diamond sponsorship does help, right?

All right. So. Uh Virtusa. Right. So this is my fifth year with Virtusa. Uh, Virtusa is a global leader in IT services and transformation services, uh, offerings. We are about $2 billion in in annual revenue. We work with about 250 plus clients worldwide and employ over 30,000 workforce of 30,000 people across several different locations across the globe. Right.

Uh, we work with eight out of top ten pairs in the United States and our partnerships with about 100 plus provider systems. Right. All with the intent of transforming their businesses and with leading with cutting edge, uh, technological advancements. Right? Uh, I know Donna talked a bit about Pega partnership. Uh, this is a legend, right? This partnership has been for 23 plus years. A lot of executive attention. Sponsorship.

There are 3000 of us in the global Virtusa Pega practice who think Pega day in and day out, right? A couple of things I wanted to add to what Donna just said was about the prolific contribution that Virtusa has made to the to the overall Pega ecosystem, right? When it comes to innovation, you know, we've been the first to implement technologies innovations such as Process AI, Voice AI, Process Fabric, so on and so forth, right? It doesn't end here. When we talk about the Pega marketplace, not many know that Virtusa has the highest number of, you know, assets, accelerators that have been that have been published in the in the marketplace. Right. Again, goes a long way in terms of our continuous effort and strong relationship with Pega. Right. Uh, let's move on to our Healthfirst relationship.

Again, Healthfirst has been one of the marquee clients for Virtusa. This partnership goes way back to 2015, where we when we just started our relationship with some app dev and QA work. Over the years, we've been associated with multiple different transformation initiatives at Healthfirst. Things such as provider lifecycle management claims modernization on Smart Claims engine. Prior auth. We've been part we've been very much plugged into some of these key marquee transformation initiatives at Healthfirst. Uh, as this relationship, uh, expanded over the last nine years, uh, you know, we take pride in, uh, in being part of, uh, over 11 different programs. Program teams at, at healthfirst. Right.

Uh, again, very strong partnership, obviously continue to work and evolve as we get into, into new initiatives at Healthfirst. Right. Uh, now let's talk about the core topic of the day, which is around provider lifecycle management and how we assisted, uh, how we worked in collaboration with Pega and Healthfirst to improve this overall cycle. Right. So Health First was no exception. You know, we had challenges in terms of lack of efficient integrated and transparent provider life cycle workflow right now. Think of think of some of the challenges such as, you know, delayed new provider onboarding. It was not easy. There were multiple different systems.

There were multiple different, uh, internal departments. Right. Getting that data in, uh, you know, managing the workflow was not very easy. Uh, complex provider data. Right. Think of some of the data quality issues, uh, that that had to be dealt with. Right. Again, building a proper workflow to do to basically set those challenges in place. Right.

A couple of more challenges included, like things around limited visibility on provider data. Right. Really it's a provider data tends to be complex, right? There are behavioral internal data, external data, different ecosystems. And I'm sure Ramesh will talk about that into more detail. Right. But these were some of the high level challenges that, uh, that we experienced as we began this, this journey, a peek into this, uh, provider lifecycle management transformation journey again. Uh, we broke it down into multiple phases. Phase one started back in 2017 with some of the discovery phases in place.

But one of the highlights here was really on the credentialing. Right? So Virtusa was one of the first partners to really, uh, automate this overall primary source verification process. I think we do it for about 12 to 13 different, 13 different SVS. It's all automated. Right. Uh, the next phase moved on during Covid where, uh, you know, talk about some of the faster onboarding, right? Again, during Covid time, we had several challenges. Uh, again, working with Ramesh and the team, we were able to really bring that down cycle down to 2 to 3 days.

Again, we'll talk about the details in subsequent slides. Right. But it doesn't end here. Right. It's not like, uh, you know, we are done with provider lifecycle management. We are now looking at the next phase, which is around how do we unify this overall provider experience. How do we have a single source of truth for all provider data that can be exposed to, you know, to other areas within Health First? So a lot of exciting work happening in this space. And I'm going to hand it over to Ramesh.

Right. To really talk about some of the business problems and challenges in more details. Thank you Prashant. So I think we'll quickly go into, um, how we are able to achieve. Right. So, um, the reason why we initiated this transformation is because, um, our majority of our provider onboarding process was completely disjointed, uh, completely manual. Um, I think any other payer sitting in this room can really understand and cope up with it, right? It's very hard to deal with, uh, when the provider data in comes with it. Right?

So what we did was we when we initially started with Virtusa PLM, first version of the PLM, we onboarded that tool into Health First and started Understanding the business processes that we have in-house and started onboarding those business processes into that. First, we found that we identified the kind of business processes that are handling and documented those business processes and work with Virtusa to onboard them as workflow, business process, workflow within Pega in infrastructure. And we created the case structure for each of the departments like provider data operations, credentialing, contracting, um, kind of manual operations and so on. So we created workflow, um, business cases and case structure for that. And also we identified business rules, what business rules that needs to go along. Which of the workflow processes should be completely automated versus some of them need manual intervention. Right. So we kind of documented that and helped the um, with Virtusa, we were able to implement that into the workflow. Um, one of the major things that used to take forever is a credentialing piece.

So that's the piece we were able to really achieve the business value and operational value. So um, in one of my slides I'll talk about how we are able to get there. Um, CQ is one of them. I think maybe we are the first payers where we are able to do the complete real time integration with CQ as part of our credentialing process. Um, especially the non delegate side where the providers are not from a health system, but we own the credentialing process, we actually do the complete deep dive of their credentialing process of all the kind of credentials. So we are able to achieve that with the integration with CQ. And we used Pega RPA process robotic process automation process to onboard. While part of the onboarding process, we have to validate around like 13 different SVS primary sources of verification. That's including the New York State education, uh, and NPS and all the other provider data sources out there.

So we're able to kind of orchestrate that into a process of the Pega so that we know exactly. For example, three sources are good. But first one has a failure. We need to for the purposes of auditing, we need to take a snapshot of that and then put that in the record so that our credentialing committee can review and take a decision whether to onboard that provider or not. So we are able to use the Pega as a business process flow to kind of use that. Just imagine if we don't have that, how much manual work somebody has to do it and coordinate that across the multiple departments. So that was a kind of a complete nightmare. So but we were able to get that. Um, and I think the final thing is like this whole onboarding process really helped not only our providers internal operations, but also our members.

So ultimately, members needs to see the see the PCP or the primary care or, or the specialist. And if we're still waiting for credentialing process, they cannot see them immediately. So we are able to achieve that value by orchestrating and automating it. And so this is a credentialing process that I specified. Um, just to go into the details. Right. So we mapped out by sitting with our operations team, we mapped out exactly what they do manually to credential a provider prior to automating this. It used to take up to three months, you know, and we were able to kind of reduce that drastically to three weeks. Um, how we are able to do that is, first, we documented the process and process, and we are able to kind of figure out which data points that we can gather, and then use that orchestration so that we don't reach out to the providers every time that we need something.

Rather, we do all the data validations upfront, and then we reach them only at the time that we really need the data. And then we use the process automation to kind of extract all the psvs. And, you know, um, we also build the business rules and definitions. Um, so our credentialing and contracting department Gave us certain rules that if everything checks out, don't wait for us. Just go ahead and credential them. If not, let's flag it and put it into work basket where credential committee will come in. Committee meets every three weeks and once. So they actually review all the requests that are pending and they make the final decision to move or not. So based on that, we process with the rest of the process, which including the contracting and data load into the claims engine system.

So we are able to achieve all of this by orchestrating to, um, you know, through Pega. And, um, we did not do that at once. Right? So we did not do a big bang. We were able to process each business operations from their manual process or SharePoint or whatever into the process of the Pega automation. So that way we're able to deliver incremental value, not a not a big bang waiting to happen for a few years. Um, one of the major implementation for us was we exchanged the data from our health systems. We called it as a roster. Just think of it as a big, complex Excel file.

The health systems has to provide us very restrictive format that our system needs to handle. So that's a very big pain point. We're still working through that. We want to kind of use new technologies. I think we talked about today, GenAI. And so all the other new tools are coming up. We want to adopt and make it make it as seamless as possible for providers as well as health system. So we want to kind of improvise on that. But we still have the current day, an Excel file that comes in from our partners.

We load that data through and using the business process automation, we're able to kind of clean the data, validate the data, and put the data into our system and process the data to all the other channels that we wanted to take care of. So PLM really helped us kind of use that process. And we also built, um, you know, data verification process as part of that. Anything that's not data is not kind of coming in a standardized manner. We standardize the data and if any required data is missing out, we actually provide an outreach. Um, so there is a work basket case that gets created and corresponding operations team reaches out to the provider to get that data. So we kind of automated that process so that it's easy to track exactly where things are right. And one of the major, um, process, um, that really helped is that, um, you know, it actually provided much more transparency. Uh, previously, if the provider submits an application for credentialing or contracting three weeks or four weeks pass by, they're not hearing anything from us.

They're they're curious. They're kind of getting nervous. What's happening? And when they call us, even we don't know our operations doesn't know because it's not in their department. Somebody else is handling it. There was no kind of complete transparency with such a centralized business process orchestration tool. Excuse me. Um, we were able to provide a very quick snapshot of exactly where the application is, whose inbox it's sitting in. And also we implemented the SLAs.

Right. So, uh, you know, service level agreements on OK credentialing should not take more than two weeks and contracting should not take more than five days. Right. So we defined very strict credentials or SLAs. And our department heads get to get notifications if something gets delayed. So we are proactively reaching out and providing that status back. So that's a huge value from our provider perspective. They feel that we are really there partnering with them, trying to onboard them as soon as possible so they feel that value and then appreciate us. Uh, okay.

The question is what's your turnaround time? Right. Yeah. So like I said previously, it used to take up to three months, 90 days. Now we are actually onboarding if it is a non delegate um, or if it is a delegate hospital, we are not even doing major credentialing. That's purely contracting and data load that's happening two weeks. So we're able to get that fast. Uh facility providers. So we also in addition to the physicians, we also onboard the facilities, which are the health centers and ambulatory centers and so on.

Um, we deployed the similar process. So there's a separate department on operations side that handles it. So we created a separate workflow process. Uh, that data is similar in nature, but there are certain nuances for facility credentialing versus a physician credentialing. So we are able to kind of accommodate those customizations and able to implement that as well. So that went through that. And that's also kind of you know, we created facility based switch as well, so that we can link how the physicians are associated to facilities and traverse the data back and forth. So we're able to implement that. Um, and we had certain different business rules and process automation for facility.

Then the physicians. So we're able to kind of improve that as well. Um, the volume per se physicians is definitely higher than the facilities. So we're able to kind of figure out how to kind of navigate those cases and stuff like that. Um, three major, um, highlights that I would say is that by implementing this, we got a complete, a seamless, transparent, uh, system for our providers, which really helped our provider operations. Um, it's a less number of, um, kind of escalations, if you will. Um, if there's any provider who's not going to on board directly call goes to our CEO. And then from there it comes back. Right.

So we're able to reduce a lot of that noise. And by proactively providing reporting as well as the end to end status. Um, and the second thing I mentioned about is we are able to cut down the overall time, uh, from 90 days or three months to almost like 2 to 3 weeks. Um, that really helped us, our providers, to be happy. And they trust us. Uh, they think that we are actually being part of the overall value based care. Um, so we are able to cater the services to them very easily. And finally, I think one of the realistic example was that, uh, during the part of Covid, right, like peak time, all the hospitals were rushing to fill in a temporary staff. They're bringing the staff from the the other cities and the states.

Um, so for that, our request was, um, can you just onboard them by tomorrow? Um, so we really kind of use the system to onboard because these temporary staff and providers coming from other states, they are not state credentialed in New York. So we have to bypass certain credentials, and also set a few things where they still can load into the system and we can see the patients. So it was it was possible for us to do an expedited onboarding process, such a crunch time, which really impacting patients in the hospitals because they don't have staff and they want to onboard staff. They were waiting on us. Um, so we were able to do that by employing, using the lot of capabilities that the Pega as well as the platform that we built offered us. So that's one of the major realistic values that I can say what we're able to get through with this. So with that, yeah, I think those are major highlights that that we saw that with overall end to end process. I'll hand it off to.

Hello. Thanks, Ramesh. I'll go back to this slide. There's an interesting call out. Uh, we take pride. Virtusa take pride on being part of this journey. And it's an amazing journey. And we happen to be in the New York Times news, Health first during pandemic, New York was worst hit, right? And, uh, we were being recognized by the New York Times, uh, telling that the turnaround time, how we onboarded the providers in such a short span and certain rules and regulations were being lived off are really amazing.

So, um, I mean, it's really praiseworthy. Uh, now, I wanted to take a step back and, uh, understand one of the basic principles which Ramesh touched upon, uh, the foundation. How did we start the journey? So it all started with a very jump start on not just using the vanilla Pega to initiate the journey on the provider lifecycle management. Rather, uh, one of the asset which Prashant touched upon, which we take pride on. We have innovation Lab within Virtusa, where we continuously innovate and build solutions. And one of the solution which is most mature into the industry is purchasers PLM solution. So we took that as a base for our health first to have a jump start, and I wanted to take some time to quickly go over what that accelerator is so that we can we can relate it back to our business wherever we are on. So predominantly the third generation, the provider lifecycle management, it went through multiple generations of, uh, engineering.

So the third generation of provider lifecycle management has predominantly six modules. And again, all of them are loosely coupled. We can start our journey, be it onboarding, credentialing or roster file or even on the recruiting. And a cliff note on each one of them is that when when we are trying to have any health organization health plan, trying to open up a, uh, operations into a newer, uh, geo code, or be it with respect to a newer county or a new business, we are getting into a medicaid got awarded to a particular organization. How do we really help recruit the providers? Right, with the right data set? So this, uh, this module helps in kind of identifying the right providers who might be applicable for the services which are provided, and again, to the line of business which is relevant to them. And once those leads are generated and the provider comes back and tells to the health plan that, yes, this is something which I really want to go for, the contracting process initiates. Right?

So this is where it's purely paperless, where we have to and fro transactions between the health plan and the providers, the hospitals, the clinics really gets kicked off. And there is a very interesting usage of Pega leveraging the, uh, the DocuSign integration to have a digital signatures being embedded into it, of having the contracting being done as the journey takes it forward. Once the contract is done with the provider, right, the onboarding kicks off. And while while we onboard, it's not just about putting the data into the into the system of truth, but also propagating back telling that, okay, it's a cost share model of fee based service or it's a value based care, right. And depending on the different rate cards and all it needs to propagate back to the claim system, pricing systems and so on and so forth. And that's where the onboarding of the provider really comes into play, where it really kind of flows into all the downstream systems, integrate with them to have, uh, the right data getting in. And while the onboarding happens, there are integration in the form of ceac to kind of get the data from, uh, for different pieces of the provider information, or be it with the address information through USPS integration, it brings up the right data, which might be the right data to be plugged in into it. So while all these things go in right. One of the most important part is the credentialing.

I think Ramesh touched upon the credentialing component, uh, significantly. Uh, I'll probably touch a cliff note in that part is, uh, while we do credentialing and credentialing, it's it's very important that we have the right certificates in place. Right. And how do we make sure the providers have reissued their certifications? And that is into the health plan systems is very key to kind of take the whole journey forward. And that is something which we in our module have tried to make it more like API and robotics based integration. Not everything can be API fight. I mean, these are external websites, right? SVS and all those websites which are very specific to that state or that county which needs to be integrated.

And then comes the configuration which is more around the whole provider data comes in. How do we really have the non part to power conversions? How do we really take care of the different pricing rules which are established as part of the onboarding? How do we really push it back to the payment systems? I mean which which finally gets into the the whole claim adjudication process. Last but not the least is roster file processing. Once we onboarded there are continuous changes, which happens. And that's the most I would say. I have been talking to a few of our esteemed customers here.

One of the biggest problem is to keep it current. How do we really keep it current? The changes in the data, the changes into the demographic or certifications and um, and Healthfirst and few of our other esteemed customers have been able to leverage this raster file module to have that being automated to a significant extent. Or how do we really service those providers into the organization? And while we did that, and by the way, we did it for 12 different customers, both regional and national payers. We take pride on doing five things for the first time. It's not just we talking Gartner talks about it. So we have been recognized by Gartner by of being the first fives in the implementation of provider lifecycle management. It can be as simple as having a near real time, near real time credentialing, which happened seven years back.

I mean, no one was really thinking about credentialing being done near real time, right? People were trying to interrogate, go into the different websites and having services being used to do those specific parts of it, or be it in the provider enrollment. How do we really automate the end provider enrollment? Which are newer providers provider getting onboarded. Kakao integration is very unique for provider unit. But having said that, the document pool which happens along with the cake is very interesting. And if we are not able to push the document along with the cake data which comes in, it becomes very difficult at a later point to kind of relate it back that how the data really came in, how do we really move the metadata from system to system? And two other points are more with respect to smart decisioning. Obviously the power of Pega really came in here.

The the way how the business rules were defined and the roster file processing, which we talked about as well, some of the key benefits which we were able to kind of, uh, put at the perspective from the implementation, which we had at Healthfirst, as well as 12 other regional and national peers, are, uh, accelerating the whole onboarding. And it goes all the way up to 70% improvement. We heard three month converting to a three weeks. It's a significant or it can be as simple as helping an And accurate data for the automation from the processing standpoint. How do we really boost the overall throughput for the processing of the data from the provider? Onboarding. How do we reduce the lead time? It's more around the accuracy, not only just the speed, but how do we really have the lead closures happening? In this case, the lead happens to be the the contract between the pair and the provider and the real dollar savings.

And some of the accolades are out here, which we take pride on being part of these journeys and we can surely spend a lot more time post this to discuss details around it. But one thing, we wanted to kind of take this opportunity in this stage today we are we just talked about third generation of PLM. So today we are announcing the fourth generation launch. So so we today heard Alan Trefler as well as Karim speaking about Blueprint, about having how do we have GenAI being embedded into it. Is this something which we can make it real from Healthcare perspective? Right. We want to make a very conscious step. Tip. We are very mindful of the phi which is around it, but at the same time provided such a segment which can really be used because these are NPI and something data which are available into the websites can be leveraged to do some kind of block chaining to have the GenAI capabilities introduced.

So what we did as part of our launch of VLM, we made it smarter, faster and better by bringing in the power of Pega Infinity 24. So the latest version of our Virtusa PLM is built on Pega Infinity 24 and has the design thinking of how do we really bring the Blueprint? So the Blueprint of our Virtusa PLM is available, so any customer who is trying to start their PLM journey would be more than excited to sit along with them to understand how the blueprint looks like. But there is a template out there. So on the morning session of Alan Trefler, he mentioned 75 templates which are out there. So this is one of them. So we have a template which is out there telling that how the GenAI blueprint really looks like for PLM and more importantly, the UX part of it, how we work together to have a rich UI not only for our internal users who are kind of onboarding, but also this contract. When it goes as a digital copy, it gets into the provider groups, it goes into the hospitals. How do we really bring those Constellation aspect of it?

And then we brought in the power of Pega Robotics, the Process Fabric and Process AI to build our new 4.0, but this is a technical view of it. I also wanted to give a business view of it what it really means from a business perspective, right? So so with this, what we did do is with the next generation technologies, we empowered our recruiting to have a geocoding provider recruiting. What it means is that it's fully integrated with Google Maps. It allows you to identify what kind of specialty we are looking for, what kind of medication. Say, for example, there is a Medicare expansion or a medicaid expansion on a particular ZIP code. It would have an ability to identify who are the possible providers whom we should outreach, instead of just making a broader outreach where the success rate might not be high. And then going into the contracting, we did leverage GenAI, though. This GenAI is on the Amazon bedrock, so we built it on Amazon bedrock.

We integrate it with Pega PLM solution to kind of have the GenAI capability of the contract generation happening. So instead of jump starting from an initial set of clauses, it personalizes and just crafts a draft copy of the contract with the right metadata put in place. So we we did introduce the GenAI capability on the contract. And interestingly on the onboarding. We didn't had anything beyond medical and dental till this point of time. So we expanded our horizon to kind of go to the mental, behavioral and telehealth as part of this launch. And the PSV, uh, though it's it's technically it might sound like we still continue to do robotics, but from a business perspective, the number of psvs which we added so 25 SVS were more added into the system. So especially it might be a great interest for national payers where it's distributed all across the US geography. How do we really take advantage of jumpstarting using this SV certifications, which are out there?

And again on the configuration as well as roster file, we leverage the, uh, the AI component to make it more accurate. I must say, this is not the end of the journey. We just started off. We would continue innovating into it. We'll work along with you to understand how we can make it better, but this is a kind of a jumpstart for us to understand how we can put technology in the forefront to have a business benefit coming around it. So with that, I will probably take a pause here and, uh, we'll open it up for questions. But at the same time, we are in booth number 20 in the Innovation Lab. Feel free to stop by. There is a teaser video if it really interests all of us, I'll play that three minute teaser video.

What? It really looks like a glimpse of the actual application. But this one is also out there in our booth, which we can surely run that real demo with you on this Virtusa LLM. So with that, I would request for any question which comes out to stand up to the to one of those mikes. Uh, for, for for a better clarity of hearing those questions out. Thank you. Hey, is this PLM built upon Pega RBC or any other suit you guys are using from? Sorry. Uh, are you using any Pega prpc engine, or are you using any particular suit for this PLM?

Yes. Great question. So yes. So this is Pega. Infinity means that it is a Pega based platform. So it is built on Pega layer. So there is a foundation layer which has all the data models, all the relevant information. We don't want to rebuild it, but at the same time we want to enhance from there. So yes it is built on Pega and it is backward compatible.

So it has a Pega 7.0.08. x and uh, it is on Pega Infinity 24 as well. Okay. And then one more question. Is this the intellectual property of Healthfirst or Virtusa? This is the intellectual property of Virtusa. Okay. And it is in the Pega marketplace, which can be downloaded for the brochure and how it really works out. But what we have done is though it is an IP, we do not charge our customer.

We use it as a value add for our customers to jumpstart the engagement. We did the same thing with our healthfirst, so once it lands into that customer ecosystem, it becomes that customer's IP. Obviously there are there are things. Ramesh. Yeah. No, I think that's what we did when we took the 1.0 version. We customized it and we own that now. So because we had to customize into our own workflows and stuff. Yeah.

Thank you. Sure. Hi. Does this PLM support. Provider contract network relationship. It does, it does. And probably one of the interesting aspect is it not only manages the relationship, it also manages. Say for example, there is a hospital group out there, Mercy Hospital. If I take an example, within that, there are multiple hospitals and each hospital would have multiple physicians.

And also it maintains the whole hierarchy. And any change which you are making at a unit level propagates back. If it is something, a global parameter which. Includes the service location as well the service location tied to the network because it is important for the claim pricing based on the. Absolutely. That's a very, very important point you brought up. So it is very critical for the pricing and the claims adjudication if you do not have it mapped. So the network basically, uh, a lot of this scenario that I have seen is that service addresses getting added to the network and terminating out of the network, uh, practitioner who is a PCP, moving from one network to another network. Right.

So a high level, you know, how does this PLM has benefited, you know, in managing this, uh, you know, uh, kind of a business scenario. Right, right. Network. And also the product lines also. Right. So the so we have certain providers have participating in certain network with a certain product line. They have for that combination, there is a separate contract with a different pricing. So we are able to map all of this with the data model that's sitting behind the scene where it's completely flexible. And and we also use an external client's pricing engine.

So we're able to map the data of what we have within PLM and PDM and map it back to the corresponding, uh, you know, claims pricing. So when the claim comes in, based on all these kind of metadata that we have behind the scene, uh, NPI and tax ID and service location, we're able to figure out, navigate through which contract we should be pricing, what network and what product line. So we're able to achieve that. So when these changes happen right. You don't have any operational procedures like these changes happens on the fly. Or do we have an operational team who gets these changes into their work basket. They review it and then they approve kind of a process. Yeah. So every change is initiated either through their existing contractual relationship change or there is certain provided demographic data change.

So we do get those data changes. Um, as we defined the process business rules, most of these are completely, you know, end to end automated as well as orchestrated. It will not stop for any manual intervention unless there is a huge change with the contract that requires additional signatures. So one last question, right. Can the PLM the new version right. Can it be containerized like a service in a Kubernetes environment? It is. It is fully on cloud. So you do have the Kubernetes and it is.

So you have the Docker images that anybody can take it and deploy the helm charts and everything. That's right. But one of the basic premises is it is built on Pega. So you need to have a Pega installation to get it working. So you can't do it in any public cloud like AWS or anywhere. So few components like we talked about the GenAI component, which is built on bedrock. Amazon bedrock. Yes, it can be. There are a few components which we may.

If there is a different technology of choice, we can surely evaluate to see how it how it would shape up. But all these what we talked are Pega based assets. Okay. Thank you. Sure. Thanks. Any last question? Okay, sure. Hi.

Thanks for the session. And once the PLM was used at Healthfirst, how much time it took for Healthfirst to go on board or to release into production? Yeah, I think a very good question. So initial onboarding, it took like almost two years for us to kind of map majority of that because we didn't have the good documentation. So we had to kind of really work with the operations team to kind of figure out exactly how they're doing today before we put something into production. So we're able to we spend like, I think 6 to 9 months just to kind of process re-engineering, if you will. Once we have that documented, we actually then work through the configuration because PLM comes with its own kind of tool. Right. So now we are able to configure that and work with the business tool and so on.

So we are able to do that and do the testing and validation with the business. So first first implementation I would say two years. And then that's a first implementation. Then gradually we added more and more. So we went with orchestration first and automation next approach, meaning that we wanted to kind of get everything off of the manual, uh, work SharePoint and processes into orchestrating into the tool and then gradually increase the automation. So kind of wherever chances are there to increase automation, especially the data loading into claim system, because our claims process is completely different data model than what we have in PLM. So we have to traverse all the data back into claims engine. So we had to automate that process. Um, you know later on.

Okay. Thank you. And I have one more question. I know this is more on credentialing, but as part of the demographics, right. Like the providers, sometimes they, uh, do the service in multiple boroughs of New York. I also some some providers work in new Jersey and because they're very close. So how do you make their demographic data consistent and up to date when filing for the claims? Right, right. So we we kind of handle that in multiple scenarios.

One, we actually look for what actually provided told us. And second, we pull the data from CQ and other third party sources so we can actually match exactly what that provider is actually located in other places. Then we actually load those locations into our system. Um, sometimes they may not tell us directly, but we hear service locations from other sites, so we reach out to ask them to clarify, you know, are they really looking at that location that we should onboard or not? Ultimately, we wait for their response before we onboard. So you call the providers before processing the claims, correct? Correct. Okay. Thank you.

Yeah. And just to add to that, right, it's not only always a push, there are also pull mechanisms which are happening. Say there is an indicator which comes in telling that hey, there is a change in address which has happened. So we can really make the system smart enough to make those edits for before even provider calls in to have those updates being made. But sometimes is also not up to date. Yeah. So how that is one industry problem. Yeah, absolutely. And we are also trying to kind of like onboard additional data sources, including like Google, to figure out if they change the contact number or the location or hours.

That's why I think we plan to use more gen AI capabilities to proactively identify the changes that are happening that they did not tell us yet, and then proactively reach out to them. Yeah. Thank you. Thank you. All right. Thank you very much for for having you all today. And thank you.