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Pega Powers Next-generation Medical Management Software

Today’s healthcare organizations (HCOs) are facing the dual challenges of huge increases in service utilization and mounting pressures for cost containment in medical management. New medical loss ratio (MLR) requirements and other reform-based cost mandates are forcing healthcare payers to produce dramatic operational efficiencies and shift their cost curves for such medical management software functions as authorization and certification of medical services; case management of care episodes; discharge planning; and medical reviews for hospitalizations, medical equipment and other medical services.


Pega 7 provides tools for business people to define the major steps of how work gets done.

Analyst Report

Pegasystems commissioned Forrester Consulting to conduct a TEI study to examine the potential return on investment (ROI) enterprises may realize by deploying the Pega 7 Platform.

Typically, medical management functions are compartmentalized, each with its own systems, procedures and specialized staff. Customer-facing processes are complex, high touch and dynamic, which has made medical management difficult to automate. Legacy medical management solutions have focused on providing clinical content and broadening functionality across the care management spectrum, leaving large gaps that HCOs must fill with additional staff. A new technology approach is being used to efficiently support the flood of medical management decisions and transactions – that technology is Business Process Management (BPM).

Built on its award-winning BPM platform, the Pega's medical management software introduces a transformational way for HCOs to manage the multi-faceted medical management area. This powerful, flexible solution allows HCOs to efficiently develop and manage high-touch medical management functions to reduce response times, achieve high levels of authorization accuracy and improve medical management consistency and compliance.

The benefits of using BPM for medical management are numerous:

  • Increase Productivity – Help avoid human error and average handle time by automating tasks that eliminate time-consuming toggling between systems and dynamically guiding service representatives through data collection.
  • Dramatically Reduce Authorization Time while Increasing Accuracy – Automatically validate diagnosis and procedure codes against the corporate set, make real-time approval determinations and send notifications to required parties.
  • Increase Control of Medical Management Processes – Use business-friendly tools to create determination logic without any need for programming assistance. Authorized business users can make updates to medical management processes, rules and data tables which are immediately executable, in accordance with appropriate medical management controls.

Representative achievements realized by healthcare organizations using Pega’s medical management software include:

  • 100% authorization accuracy
  • Over 60% of changes managed by business users
  • 40% reduction in average handle time
  • 25% improvement in operator productivity
  • 30% reduction in technician training costs
  • 12% increase in authorization STP