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success story

Nearly $40M in budget impact expected for leading American payer

with intelligent claims editing using Pega Smart Claims Engine (SCE)

The largest health insurance payer in New York City (NYC) used a mainframe claims adjudication system that could not make a real-time connection with the claims editing system, resulting in delays. The delays in time to adjudicate the claim and time to release the payment were causing additional challenges. The client enlisted Virtusa to complete a three-phased project, orchestrating the process from the mainframe to the claims editing software using Pega Smart Claims Engine (SCE).

The Challenge

Legacy claim adjudication system unable to edit in real-time.

Virtusa assessed the claims editing process and found that during the post-adjudication process, the claim information gets retrieved by Pega, which pulls the insured member ID from the claim information and then queries the claims database to pull all the historical claims for the member. Since the historical claims are from one to three years old, they get sent to the claims editing system for validation and any necessary updates. 

The historical claims and the associated information are gathered and sent over to the third-party claims editing system.  

By using this process, the client faced multiple challenges, including:

  • The legacy platform lacked APIs and had difficulty handling the large volume of historical claims data 
  • Batches sent and received from third-party editing software caused huge delays
    • Delays affected the overall time to adjudicate claims and release claims payments 
  • The overall process is slow and inflexible
  • Difficulty managing multiple editing rules
The Solution

Pega SCE platform facilitates real-time editing of adjudicated claims.

Virtusa orchestrated the claims editing process by implementing Pega SCE to connect the legacy adjudication platform and the editing software. Pega SCE facilitates validating the adjudicated claims to ensure data validity and completeness and check for fraud, abuse, and waste.

The platform:

  • Watches and stores the adjudicated claim information in a massive Kafka database.
  • Listens to the Kafka database, retrieves the claims data, assembles them in the format expected by the third-party software. 
  • Exchanges the claims data with the third-party software using APIs. 
  • Receives the response and sends updates back to the legacy claims adjudication platform through the MuleSoft middleware tool 
  • Sends edited adjudicated claims to be processed for payment.
  • Gathers all the updates to past historical claims and sends them over to the third-party software for validation
  • Using this platform and process offered the payer real-time claims editing capabilities. 
Pega Smart Claims Engine Solutions
The Benefit

Real-time editing with more flexibility and better maintenance.

Orchestrating the claims editing system with Pega SCE helped the client to:

  • Streamline claims adjudication
  • Improve claims adjudication timelines 
  • Enhance payment integrity and transparency
  • Reduce claims rework
  • Increase the first-pass rate 
  • Improve the maintenance of the editing rules
  • Enhance the quality of the claims payments to provide medical cost savings
  • Result in an expected $38M impact to the operating budget with over $8M saved in vendor costs and possibly an additional $30M in medical cost savings over three years

Our client will see additional savings throughout the claim’s lifecycle on infrastructure and maintenance because of better reusable components.

Transform how you process claims and unleash productivity

Learn more about Pega Smart Claims Engine

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