Health insurance companies face a huge challenge maintaining their provider network. The provider database of any health insurer is error prone. The direct impact of having erroneous data impacts the business in many dimensions. There can be inaccurate provider directory or incorrect claim payments sent to providers due to wrong addresses. With the increased scrutiny from content management systems (CMS) on the provider data quality, its high time payers adopt serious technical and business strategies to bridge the gap.
In this article we will look at the top 5 considerations for successfully implementing a provider life cycle management solution for a payer using Pega business process management (BPM) and robotics process automation (RPA) for higher performance and returns on investment (RoI).
Case management feature is the foundation for a successful product life management (PLM) implementation. This feature was introduced in Pega version 6.x, and evolved into a very mature state in the latest 7.x versions of Pega. The case designer screen offers many features out-of-the-box (OOTB) to create a case, design the stages and life cycle, and establish the parent-child relationship among the cases. A case will have multiple stages which in turn is composed of multiple steps. Each step can call one or more workflow. In a PLM solution, typically every provider load will be a bare minimum of a contract case, under which multiple provider cases will be added. Also, for every provider 2 business functions are essential credentialing and configuration or provision of provider in the claims systems. A typical case structure will be as below:
Overall, the case life-cycle will be envisioned as:
Case management comes with default SLA configuration which can be applied at the case level itself, the stage level or the individual workflow level.
As a BPM software, Pega offers robust workflow capabilities. In a typical PLM life cycle, the onboarding process is a complex, multilayered process, involving multiple actors. Pega's workflow offers a variety of OOTB capabilities including smart shape options and the option to spawn into multiple processes. All these parallel processes can be configured to culminate at a common endpoint. Pega also offers the circumstancing feature which would enable the same workflow to behave differently for different contexts such as statewise or provider types, etc.
An efficient data model is the foundation for performance and maintenance of any enterprise application. For PLM implementation, utilizing the data model offered by Pega Healthcare Industry Foundation (HCIF) layer will be the most appropriate. HCIF provides extensive data layering which caters to provider, member, claims, etc. Using HCIF provided data layering also helps to reduce the development time.
The process of provider credentialing is mandatory in a PLM life cycle, and it is a heavily manual process. It involves verifying multiple sources to establish the education, prior experience, and malpractice information about the provider. Pega's robotics platform ‚OpenSpan can do all these sequential tasks without any manual intervention or efforts. OpenSpan can automatically crawl to various verification sources to check for the provider record, gather the information, and if needed, take screenshots as well. If there is a malpractice record against any provider, OpenSpan can take the necessary decision such as routing for manual review or rejecting the case. Extensive use of OpenSpan RPA in every possible way can result in huge RoIs.
For an enterprise application, reporting and dashboards are indispensable assets to measure performance and TAT (Turn Around Time) of the process and employees. Pega provides a very efficient, intuitive reporting framework which can help in depicting the exact state of the application. There are a variety of graph options available OOTB. In the latest version of Pega, end users can configure their dashboards.
In addition to the above mentioned features and along with an ocean of OOTB features in Pega 7 platform, it is the quintessential software to build an efficient, scalable PLM solution for process improvements and achieving high RoIs.
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Today's communication service providers (CSPs) operate in an increasingly competitive environment. In addition, many face heightened regulations, skills shortages, and rising customer expectations. To adapt, they must explore effective ways to consolidate data and streamline processes, maximizing the impact of their workforce.
Pega Systems Architect