Case Study

Automation Streamlines BPO Claims Processing

The BPO selected Pega to automate claim processing rules and allow health plan clients to select from a menu of options as well as customize unique processing actions. To maintain auditability, the BPO used Pega to create a compendium of business rules associated with pended claim processing. Now, edits that had to be sent back to client plans for resolution are automatically resolved through plan-specific rules specified by each individual plan. Rule automation, tracking and reporting has also improved mandated federal program compliance and auditability, as well as performance reporting to health plan customers.

The Pega solution perfectly fits this BPO’s vision for incremental legacy modernization by providing mature business technology to address legacy system deficits while improving business performance and responsiveness. Pega delivered specialization and automation capabilities that have reduced pended claims volume and processing costs, decreasing pended claims by as much as 20 percent for constituent plans. “The use of business rules and plan exception processing customization has been really successful, adopted by over half of our health plan clients,” says the Business Architect, with several plans choosing to implement more than one specialized edit. What’s more, the BPO has accelerated provisioning of new edits, and provided enhanced visibility and audit capabilities through the Pega solution.


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