success story

70% faster provider onboarding for a managed care services provider by integrating Pega PLM with SalesForce

Our client is a leading provider of US-based managed care services targeted to government-sponsored healthcare programs like Medicaid and Medicare, as well as health plans and prescription drug plans. It had won a large contract to deliver healthcare services and was looking to ramp up its provider onboarding process by replacing their aging, legacy CRM.

The client chose to partner with Virtusa owing to our vast experience in successfully deploying large Pega-based transformation projects. The Salesforce-Pega integrated provider onboarding solution brought several key enhancements to the onboarding process and accelerated the timelines by 70%.

 

 

The Challenge

The client had won a contract to deliver healthcare services across 15 states in the US.

With provider onboarding playing a crucial role in executing this contract, the client had to overcome multiple challenges and onboard providers quickly and successfully. Along with the scale of execution, the client had to address several key issues:

  • Different states across the country had different rules and different systems in place. Integrating each of these disparate systems was becoming a huge challenge – not only in terms of establishing seamless connectivity between the systems but also to maintain data integrity
  • Onboarding providers involved a lot of documentation and needed detailed information from the providers. This information stored across spreadsheets and Microsoft Access had to audit trail. This was not compliant with CMS regulatory requirements
  • Resistance to change due to a perceived increase in workload with migrating to a new system
  • More than 30% of the claims were getting rejected because of data quality issues, and the operational costs for fixing rejections was extremely high
The Solution

There was an immediate need to replace IBM Emptoris, with Pega’s Provider Lifecycle Management (PLM) capabilities, as it had several product limitations.

Key highlights of Virtusa’s deployment included:

  • Automating onboarding by integrating best in breed CRM systems –Salesforce CRM (existing) for the front-end with Pega’s PLM for the backend
  • Enhancing capabilities to manage workflow, service level agreements, business rules, integrations with internal systems, and provide regular updates to various consuming systems
  • Automating roster file processing with capability to manage multiple templates and validations based on state, lines of business, and specialty
  • Improving data integrity by stabling Pega PLM as the single system to maintain data integrity between Salesforce, Cactus (Credentialing) and Xcelys (Claims)
  • Designing and building a common document repository for all provider related documents with required access and controls
The Solution
The Benefit

The client realizing substantial ROI from this transformation project:

  • Providers could be onboarded within 30 days; in comparison, the earlier process took 90 days
  • Efficient workflows meant that pending claims were reduced by more than 50%
  • Better data integrity meant that reporting and case status updates happened in real-time, thus reducing the average call handling time by 50%
  • Ability to deploy the onboarding solution across other states within 60 days
Digitizing patient care for positive health outcomes
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