5 focus areas to accelerate Provider enrollment using Pega BPM

Multichannel Provider Data Intake

Provider data is obtained from a variety of input channels such as CAQH, Federal and State Rosters and exclusion lists, malpractice claim history etc. and this data are often incomplete and outdated. Pega_HealthcareCleaning and processing this data involves huge time and effort, in a typical case more than 60% of the processing time and effort are spent on validating and correcting this data, as this requires back and forth routing between multiple users.

Pega makes this mammoth task simple by providing a variety of out of the box integration and process automation features, such as multi-channel integration, robust rule engine, intelligent decision making and routing, smart task creations, auto alerts etc.

Intelligent Classification of Requests and Smart Routing

In day-to-day business processes, assigning the right request to the right user is always a challenge. For credentialing, there are around 80 different types of requests ranging from a new provider to reinstatements or voluntary relinquishments. There are different state regulations and specialty type, and routing these requests to the correct business user, fulfilling the pre requisite conditions and skills can add up to the delay.

Pega streamlines and efficiently manages the workflow and eliminates the manual process. The skill based routing feature of Pega ensures that the right case is routed to the right worker thereby increasing the TAT and enhancing productivity by ensuring that SLAs are controlled by alerts and notifications.

Parallel Processing Opportunities

Normal business processes operate sequentially like a typical shop floor model. This sequential business processing always consumes more time, thereby extending the overall processing. And there are business processes which can be performed in parallel, this can greatly reduce the processing time.

Pega’s case management capability is an ingenious solution for parallel processing that can breakdown the case to multiple subcases and in turn to multiple tasks. In the enrollment process the best of these capabilities can be leveraged to create parallel subcases between credentialing and configuration and within credentialing subcases multiple tasks can be created to handle the various provider source verifications etc.

Digital Correspondence

1000s of dollars are spent by organizations each year sending and receiving correspondence through paper mail making way for missing information and follow ups, which becomes an additional overhead for already chaotic manual process.

As per the latest analysis, around 25% of the total providers, who sign up for the contract would never complete the enrollment process due to missing correspondences and improper follow ups.

Pega totally eliminates this complexity by providing efficient out of the box features for sending and receiving correspondence, by handling email, FAX and Phone text.

Some of the additional Pega correspondence features:

  • Include digital signature to verify the center identity in outbound correspondence
  • Generate attachments for inclusion in emails (.doc, .pdf, .xls, etc.)
  • Monitor and route incoming messages according to defined business rule
  • Interface with Microsoft Outlook
  • Directed web access that allows external users to execute an assignment
  • Error handling for problem emails

Provider Site Visits and Data Collection

  • Most states have made site visits mandatory for PCPs and facilities and this adds time to an already delayed process. Direct implications of this are missing, delaying information to the already started process.
  • Pega’s Anytime Anywhere mobility brings the provider much closer to the process and makes the life of the point of contact executive and the site visit personnel’s life easier.
  • Pega is compatible with both apple IOS and Android.

As per CMS regulations, starting in 2016 private medicare plans must keep updated doctor directories. Failing to do this will attract penalties. Most state regulations require their plans to update their directory monthly or weekly in California.

Pega’s real-time multichannel integration capability will help in keeping the provider directory abreast, thereby ensuring CMS complaint.

Leveraging Pega BPM’s features and best practices, Healthcare organizations can quickly ramp up a very strong and well distributed provider network thereby serving the best for their members.

Authored by:

  1. Kuzhalan Samydurai, CHP, Lead Business Architect, at Virtusa
  2. Veerappan Rathinam, Pega Lead Systems Architect, at Virtusa

Kuzhalan Samydurai

Manager - Business Consulting, Virtusa. Kuzhalan Samydurai has helped lead healthcare organizations for more than a decade by providing IT solutions for their complex business problems, enabling their growth and making them complaint with the industry regulations

More Posts