The Client: Rulesware’s client was a pharmacy benefit manager (sometimes called a PBM) that helps health insurers, employers, individuals and seniors on Medicare. Their primary business is processing claims.

The Problem: While fulfilling a request to analyze one of our client’s automated processes, Rulesware noticed that the client’s overall intake process (essentially the way requests entered all of its systems) was inefficient. Most of the company’s requests came in at that time through faxes and phones, as well as email, and would be manually and individually processed, ending up in one of many Lotus Notes folders. If urgent, a request would get moved to an “Urgent” folder. Employees would then access Lotus Notes to look at a particular fax, and take manual action from there.

The problems were clear: because the process was purely manual, it relied on specific people being there to act. “And if someone didn’t monitor those inboxes–if they were sick or away on vacation, for example” notes David Bunge, Rulesware Principal Architect. “It wasn’t getting done.” And of course any inefficiency resulted in delay of care to the client.

The client’s existing systems did have an Intake process within its PA process, but it remained manual and was embedded in one plan-specific system, and therefore was not usable outside of that single application. Rulesware observed that Intake was a necessary element in all of the client’s business.

Rulesware’s Approach: Rulesware’s suggestion was to break off the Intake element, automate it entirely, and optimize Intake as its own application for the benefit of the client’s business as a whole, including–but not limited to–a single plan.

“It was a fairly simple solution: it was linear, involving three or four steps,” David Bunge notes. “But our driving goal was always to keep the company’s big picture objectives in mind: we wanted to make sure we were making something that in five years could be fully automated so that nobody would have to do anything manually at all.”

In our collaborative planning meetings with the client, the decision was made to build the Intake application in Pega 7 following an Agile methodology. “Right from the start, we collaborated closely, always showing the team demos and prototype of what we were thinking,” David Bunge notes. “We wanted to maintain close contact so they could understand our thinking, and literally see the solutions we were proposing.”

Rulesware’s first order of business was to implement electronic and multichannel intake, Bunge says, so that the application could consume the request and automatically define where it needed to go. The system also had to automate eligibility checks, ensuring that the requestor was actually a member of the care plan and has the benefits. And of course the system had to carry out checks on the drugs and providers.

Once the Intake process was complete in a smart and timely fashion, all of the information collected then fed into the Prior Authorization application.

The Results: Rulesware set out to create a system that efficiently functioned as the single source of intake for all lines of the client’s business, and the client acknowledged that we fully accomplished that objective.

The “Single Intake” application is now a key component in the client’s system for completing all clinical reviews. Single Intake allows the client to funnel all Prior Authorization requests from all channels into a single PA request process flow. The ability to perform common verifications on PA requests and route PA requests to the appropriate clinical review system will help the client to reduce their overhead cost per PA, reduce turnaround times, and generally speed up decision-making for patients.

“Before we  built the Intake system, every line of business handled things differently; there were completely separate processes maintained in different departments,” David Bunge says. “Everyone was in their respective silo, doing their own thing.

“What we did was bring in a single process to improve efficiency, reduce manual effort, and ultimately save the company money. They were very happy with the result.”

Indeed, a senior member of the client team wrote Rulesware recently to thank the team for their focus and engagement, noting that “the Single Intake component is key to our overall simplification and optimization, and it is also great example of how many small pieces have to come together to create an application.”

Takeaways

“I think what the client appreciated most about Rulesware was our willingness to treat them as a partner from the start, and to pay close attention to their overall process, rather than jumping right into technology,” Bunge says.

“And that’s just part of our DNA at Rulesware: we know that if you don’t understand the business process you’re never going to build a good solution in Pega. The ability to ask the right questions, occasionally push back a little to really dig into the core problems, and ultimately to understand a client’s deeper problems is key for us. And once you have this foundational understanding, the technology part is easy.”