Health Alliance Plan gives itself a health boost
13% increase in timeliness
33% increase in accuracy
66% increase in productivity
"In an era of consumer-driven healthcare, having an effective appeals and grievance management system and processes can provide any health plan a competitive edge."
The Business Issue
Like other health plans, Health Alliance Plan (HAP) faced the challenge of a highly manual appeals and grievances process that was extremely labor-intensive and time-consuming. With the pressure to meet state and federal regulations and ever-evolving mandates, it was essential for the plan provider to accurately track appeals and grievances and ensure a low error rate.
Pega helped HAP streamline its entire appeals and grievance lifecycle –from origination to resolution. The solution is based on a configurable process automation framework that streamlines the inflow of all appeals and grievances from multiple sources: Web, email, fax, walk-ins, etc. Pega’s smart rules engine, which prioritizes transactions based on case urgency, enables skill-based routing, resulting in faster assignment of cases.
“Our success was almost immediate,” says Garima Aggarwal, director of customer experience at HAP. When the insurer tracked productivity, timeliness, and accuracy, it discovered it had exceeded all of its metrics.
HAP doubled its productivity because of process standardization. Pega’s insights and guidance, based on its 360-degree view and simple and clear process, enabled the plan provider to improve service for members and providers alike.
Product Area: Customer Service
Challenge: Customer Service