The Client: Our client is a not-for-profit health insurance company that serves its members through a variety of government-sponsored programs and private health plans.

The Problem: Our client did have a working system for pre-processing claims, but were unable to monitor all inbound claims and/or the status of processing those claims. They were also not able to easily or quickly make changes to the preprocessor in order to be better able to adjust to business needs.

Our client wanted, in general, to improve the first-pass rate for processing all claims; to improve their claims auto-adjudication rate; and reduce claim fallout and manual re-work. Ideally, they also wanted to create a closed-loop system for reporting all intake actions.

The Solution: Rulesware approached the problem by conducting an operational walkthrough with the organization’s leaders and system users, in order to clarify our understanding of all current processes and tools. We worked closely with the client to develop a solution vision for the replacement of the current pre-processor, ensuring that we shared an understanding of both the approach and scope of the vision. We then established a scrum team of Rulesware and client team members, and got to work designing, building, testing and implementing the solution.

The solution was to implement a Pega rules engine and case management solution for the preprocessing and inventory management of inbound claims, ultimately providing the client with the capability to quickly add business rules and make changes to the preprocessor, in response to changing business needs.

Because our client works with scrum methodology, Rulesware leveraged the scrum methodology that is in use with other clients, along with standard scrum procedures and ceremonies, as a core set of procedures to establish the detailed approach and agenda for each of the agile/scrum phases. The scrum team was comprised of seven team members from Rulesware and four from the client’s organization, with the Rulesware team members distributed across El Salvador and the US.

Ultimately, Rulesware developed a rules engine based solution, using the Pega Claims Repair framework. This solution has multiple integrations with the client systems; a reporting component to provide visibility into the electronic claims inventory during the intake process; and an initial user view to look up and review the preprocessed claims.

Results: Our client now has transparency and agility in the processing of claims during their intake process, so that it’s possible for their business managers to easily and quickly maintain and/or adjust business rules for those inbound claims. The solution has eliminated manual steps in the process, has provided efficient reporting in support of process controls, and has dramatically improved the data quality rates of the preprocessed claims and reduced manual interaction on those claims.

Our client now reports a 40% decrease in provider assignment, reducing manual interaction and improved claims processing times.

We are also very pleased to have provided thought leadership and best practices for our client’s scrum implementation — which we’re proud to say have been adopted and established at their enterprise level — as well as for the organization’s Pega enterprise architecture implementation.

And best of all? The Rulesware team made such a positive impression that the client awarded Rulesware a project in the client’s clinical area and another project in the claims area.

In the words of one of our client’s senior team, following one of Rulesware’s demos: “I LOVE the claim BPM stuff being delivered! I love what’s being delivered and the way it’s being delivered!.”