Healthcare Go-Live

A large health insurer needed to upgrade their legacy system that was taking up to 40 minutes to process batches of 5000 Medicaid enrollment transactions.

The Problem

A health insurace company, with more than 1.2M members, legacy system was taking between 20 to 40 minutes to process batches of 5,000 Medicaid enrollment transactions: too long. The client knew that the older legacy system needed a complete upgrade. Their business stakeholders were looking for a new solution that was fully production-ready with end-to-end functionality.

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The Solution

“We set out to create a new Medicaid On-Exchange Pega Orchestration application, a solution that would take in ANSI 834 enrollment transactions, process them, route the transactions that can’t be automated to a team for triage, then update all the appropriate systems. We knew we had to create a sizeable application, with more than 3,500 business rules, to meet the client’s requirements. We focused in on efficiency, coming up with a unique Transaction Queuing technique in Pega that would greatly reduce the processing of transactions out of sequence, which often causes downstream system errors.

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.”

The Result

“The client’s Medicaid end-users are extremely pleased with their new Pega-centric application—in part because the solution has 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.

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.

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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