Building a Smart Claims Processing Solution

A global health services organisation reconfigured its claims systems, eliminating 25% to 30% of time spent on case processing

Building a Smart Claims Processing Solution

A global health services organisation reconfigured its claims systems, eliminating 25% to 30% of time spent on case processing

The Challenge

A global health services organisation, with insurance subsidiaries that are major providers of dental, medical, Medicaid and Medicare plans, needed to modernize its claims systems to be more flexible and configurable.

The Solution

We played a key role in the definition and delivery of the Pega Smart Claims Engine, including soliciting requirements, user story creation and grooming, sizing initiatives and leading Pega DCO sessions. We focused specifically on identifying processes and system elements that could be created in a way that would make them configurable so that future needs could be addressed.

This required a delicate balance of user configurability and a strong system framework to ensure that specialized users were able to make changes, and that these changes would not negatively impact system performance or cause major exceptions that would cause claims to be incorrectly adjudicated.

The Results

The Pega Smart Claims Engine enabled users to reduce time spent on case processing by 25% to 30% in addition to significantly reducing the potential for human error.