Earlier this year, one of our favorite healthcare clients went live with the new 834 Medicaid On-Exchange Pega Orchestration application.

It’s a solution that takes in ANSI 834 enrollment transactions, processes them, routes the transactions that can’t be automated to a team for triage, then updates all the appropriate systems. It’s sizeable, with more than 3,500 business rules, and our Rulesware teams are continuing to enhance it.  

Because the application is meant to serve as a full replacement for this client’s legacy Medicaid Enrollment application, the new Pega Orchestration version needed to be fully production-ready with end-to-end functionality. Had it not been, the business stakeholders would not approve or adopt it.

The Results

The client’s Medicaid end-users are extremely pleased with their new Pega-centric application—in part because the solution delivered an immediate efficiency gain of 78.5% over their legacy system. (This calculation is derived from the historic 14% error rate per day in the legacy application versus the new, improved 3% error rate using our Pega solution.)

Much of this success is attributable to the unique Transaction Queuing technique we created in Pega, designed to greatly reduce the processing of transactions out of sequence, which often causes downstream system errors.  

Another big win: the new Pega solution is processing batches of 5,000 transactions in 7-8 minutes, compared to legacy processing times of 20-40 minutes. Who doesn’t like saving time?

We’re pleased to report that the Rulesware team received accolades from both the client’s business and IT stakeholders, including praise all the way up from the COO and CIO.

Timing

The production-ready and tested application was designed, developed, tested and made ready for production in about six months. It was built leveraging the Healthcare Industry Foundation assets, and came shortly after two other releases that support Nursing Home cases and a Disenrollment process.

Next Steps

So where are we today with this evolving solution?

We continue to work collaboratively with our fantastic client, adding new lines of business to the solution so that it can support these same processes outside of Medicaid.

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If you’re interested in saving time and boosting efficiency through custom Pega solutions, do get in touch! We’d love to talk.

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