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success story

$3M+ in yearly savings and significant improvement in business outcomes

Realized for a multinational healthcare payer with Virtusa’s Pega expertise to build a centralized credentialing hub

A U.S. multinational healthcare insurance provider needed to streamline its credentialing system along with workflows and processes. Virtusa orchestrated the credentialing process using the Pega Case Management System and Pega RPA. 

Applications were used as a central business rule execution engine. The main application eliminated and reduced manual business process activity, enabled comprehensive skilled-based routine and auto-assignment of work, automated data-driven decision-making, and enabled real-time knowledge management, and guided workflows. Further, the application turned real-time insights into business performance KPIs and information, connecting other systems and processes into this central credentialing hub.

The application gets data from various sources, including scraping from external websites, performed through Pega RPA. The business rules engine built using Pega works with the complex data accumulated across the board and presents appropriate actions to the end-user.

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The Challenge

Breaking free from information silos, credentialing inefficiencies.

Efficiently orchestrating the practitioner credentialing process was a challenge for the major healthcare payer due to multiple siloed applications and the lack of unified processing platforms, intelligent UI, and a rules engine to execute a vast set of business rules.

The already existing system had inefficiencies in terms of time and data silos, which increased overhead costs. There was a lack of visibility into the management process and credentialing system, resulting in a timing lapse.

The payer also faced challenges with:

  • The addition or modification of business practices
    Due to the lack of a unified system, having to modify/add rules and processes across multiple applications led to increased overhead costs.

  • Training new hires
    With no processes in place to train new staff, it added to the system's complexity in the form of history and audit reporting, incurring additional costs and unplanned downtime.
The Solution

Intelligent provider lifecycle management using Pega.

The provider credentialing process as part of the organization's practitioner onboarding was manually intensive, with employees having to work across multiple applications.

Virtusa built a solution for case management, on Pega to address this. The application:

  • Takes input from various internal and external systems
  • Has an RPA bot to pull data from various sources, including screen scraping external websites
  • Processes the data as extensive business rules depending on the practitioner type and state
  • Uses an intelligent work management capability and an auto-routing assignment module to route the most appropriate case to the correct user
  • Targets the credentialing of practitioners and subsequent phases targeting other provider types.

Virtusa also added an elaborate real-time knowledge management module to the system to train users on the credentialing process to reduce the time it takes to onboard a team member.

Centralized Credentialing Solutions
The Benefit

Intelligent Practitioner Credentialing using Pega Infinity and RPA automates, saves costs, and helps in effective decision-making, acting as the only centralized system your organization needs..

We implemented the application in a phased approach. The benefits in this first phase alone are tremendous. The client:

  • Saved $3M per year in operational costs
  • Reduced the average handle time (AHT) by 38%
  • Gained effective business process management
  • Automated data-driven, decision-making
  • Automated skills-based routing and auto assignment of work
  • Achieved real-time knowledge management
  • Reduced onboarding time for new hires
  • Improved quality of business outcomes

The application was launched for an initial set of 20 pilot users and gradually all 150+ users will be onboarded on the application.

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