Pega Smart Claims Engine

Virtusa’s product engineering and innovation expertise ensure your organization gets the best out of Pega SCE. The platform helps streamline claims modernization with the following features: 

• Cognitive computing and machine learning: Payers can offer personalized solutions for everyday consumers.
• Blockchain: Helps reduce red tape, increase interoperability, and improve consumer relationships within the healthcare payer community.
  
• Analytics: Improve patient satisfaction and patient flow, reduce avoidable readmissions and adverse events.
  
• Microservices: Create new ways to connect and engage with patients.
  
• Everything-as-a-Service: Combination of data science, mobile applications, and big data to manage chronic diseases, reduce cost, and increase the reach of healthcare.

Virtusa’s Pega SCE provides additional applications to the payer’s claims processing system to streamline workflow. The benefits of Pega SCE include:

• Easily configurable next-gen claims platform
  
• Cost efficiency
• Optimized business processes
• Guided and automated workflows
• Superior user experience
• 24 hours a day – 8371/P/D processing, approximately 12 8371/P/D files processed daily
• 92% improved first-pass rate – medical
• 80% improved first-pass rate – outpatient
• 55% improved first-pass rate – inpatient 
• >25,000 claims pre-adjudicated/hour 

Additional benefits include:

1. Straight-through processing (STP): Reduces the overall per-claim processing cost and improves operational efficiency. It also lays the foundation for processing potential point-of-care, real-time submissions in the future.
   
2. Transparency and visibility: Increases engagement and provides claims operations users and policy managers with a sense of ownership of the adjudication systems, resulting in active contributions to continuous improvement.
   
3. Business flexibility: Optimizes network contracts by enabling appropriate reimbursements and improving implementation plans for upcoming regulations. Also, it helps teams avoid repetitive, low-value tasks and focus on higher-value work efforts. 
   

Virtusa’s Pega SCE guides clients through a complete journey of the claims modernization process. Your organization will benefit from simplified workflow and business flexibility by following the Pega SCE journey: 

1. Discover

• Current state assessment
• Financial business case
• Obsolescence review
• Define overall roadmap

2. Strategize

• Vision and objectives
• Focus areas and KPIs
• Define implementation plan

3. Design

• Refine requirements
• Define end-state architecture
• Futuristic design

4. Build

• Build smart-modularization simplified
• Execute SIT and UAT
• CICD Pipeline

5. Go-Live

• Support service automation
• ‘Plan for change’ service

Pega claims management creates an automated end-to-end process to improve workflow, reduce burdensome tasks, and eliminate legacy inefficiencies. It incorporates intelligent processes, flexible rules, and advanced capabilities that automate forms, manages complexity factors, and maintain compliance. The claims process is simplified with enhanced search and data retrieval, making it easy to find policy information. Advanced case management rules provide automated approvals and wide-scale views of claim profiles. Cycle time is managed with real-time and historical insights, recording all activity in a case. Claim resolution is streamlined with business-defined rules that calculate the risk of each claimant and forecast outcomes to better personalize responses in the future. 

Virtusa’s Pega SCE is a platform that increases claims processing productivity for healthcare organizations. A digital claims process performs tasks faster, improving customer engagement and lowering costs. Machine learning can personalize customer solutions, allowing for greater flexibility in healthcare services. Pega claims management enables core modernization to address customer concerns, create better health plans, and enhance product development. Healthcare groups can benefit from fast claims resolutions that streamline member experience, improve accounts payable, simplify contract management, and speed up patient onboarding. 

Split join allows multiple processes to perform parallel to each other in sub-processes. Two different application processes can occur simultaneously and rejoin the main application once both are finished. Split join also provides flexibility when the user wants to resume the primary application process by selecting which sub-processes require completion. A spin-off is an ability to add a work object to a running process without stopping the main application. The added object can run in the primary process or a second flow. 

It is a system of record that a person or automated process uses to monitor the cycle of a claims workload. It eases all processes within the insurance value chain by gathering, analyzing, and executing information around a claim. It allows control over incident intake, legal liabilities, and claims administration. Pega claims management systems can help healthcare groups define claim types, manage transactions, and understand payment details.