THE CLIENT

A not-for-profit health insurance company.

BACKGROUND

When our client came to Rulesware for help they needed to transform expensive, unscalable, error-intensive manual processes with digital automation.

As a plan working primarily with the underinsured, mostly Medicaid participants, their main differentiator had to be the strength of their Provider network. Therefore, a fundamental focus of their digital transformation was strengthening the relationship and trust that they share with that network. That meant improving quality, efficiency and transparency.

The client needed to be able to process a variety of different claim types with a high level of transparency. However, they also needed the ability to adjust their business rules as state regulations changed. Because theirs is a complicated business with many moving parts, they required a powerful and flexible solution.

Although the client already had a legacy pre-processing tool in place, it was very opaque and difficult to modify, resulting in slower processing times and more manual intervention. Those manual interventions further reduced claims processing efficiency.

They selected the Pega platform to improve their antiquated claims intake processes.

RULESWARE’S APPROACH

Because the client already had a software solution in use, it was easy for them to explain their basic needs to Rulesware. There were elements of the claims system that were clearly working, and many that were not. Instead of simply patching the problems, the Rulesware team and the client collaborated to develop the business processes and rules that would drive the results the client desired.

Using the Pega rules and case management capabilities to preprocess and manage claims was fundamental to an end product that produced real results. A great example of this was the improvement to the Provider Creation Process, which was optimized as part of the Claims Intake Redesign. A key issue in this workflow is the Provider ID Assignment process. One particular metric is Provider ID not on file (PNOF). This claims rejection indicates that the payer does not recognize the billing information (NPI and Tax ID) being sent on the claim. This was a major issue for our client. The old process would assign “Dummy IDs” and cause expensive downstream processes to address the problem.

THE RESULTS

The new solution designed by the team at Rulesware, in collaboration with the client, has achieved impressive results:

• For the initial release of the project, the client set a target of 50% reduction of the PNOF occurrences. In a period of four months (April to August) PNOF was reduced by 82%.
• During the same period they reduced instances of National Provider Identifier (NPI) corrections by 36% on a target of 25%.
• In addition, they retired their legacy pre-processor, removed 600-700,000 human touches from claims processing, and dramatically reduced their claims adjudication rate.
• Overall, they reduced the volume of incorrectly processed claims by 67%!

And, because of the increased transparency available in the new system, the client is able to check in on claims at any stage of the process to determine current statuses and can fully report on a variety of metrics at any given time.

The entire Claims Intake Redesign was delivered over three releases with a total of 7,718 Pega rules. Across all three releases, there was a total of 17 defects or a defect rate of 0.22%!

“Pega allowed us to replace an antiquated, rigid claim intake process with a flexible, transparent process that can be easily updated and kept current.”
-VP, Claims

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