Case Study

Cutting Medicare Part-D Case Completion Time to Minutes

The Center for Medicaid and Medicare Services (CMS) mandated that all Part D Medicare Pharmacy Benefit Managers (PBMs) execute a program to decrease medication overuse by pinpointing fraud, waste and abuse. For one Top Five PBM the utilization and overutilization program was a highly manual effort, including manual access to many different systems to do the complex analysis needed to process over 200 million pharmacy transactions per year for both commercial and government health plans. Deployed on the cloud in less than four months, Pega has expedited this PBM leader’s compliance with CMS implementation timeframes, delivering case management and automation capabilities to execute the CMS mandated medication overuse program.

By consolidating required patient, claim and medication information, Pega has slashed case completion time from days to minutes. ”We’ve got a decrease in the number of manual touch points... The pharmacist isn’t, grabbing information from here and here and here, and putting them together. Now it’s all in one central place. We also know what happened to the case. There’s no doubt at any point in time where a case is. That gives us increased auditability,” says the PBM’s Strategic Solutions Director. The application also enforces CMS guidelines and service level requirements, providing transparency and documentation for compliance reviews.


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