Health insurance companies face a huge challenge for maintaining their Provider network. The provider database of any health insurer is error prone. The direct impact of the having erroneous data impacts the business in many dimensions like inaccurate provider directory, incorrect claim payments sent to providers due to wrong address. With the Increased scrutiny from CMS on the provider data quality, its high time payers adopt serious technical and business strategies to bridge the gap.
In this article we will look at the top 5 considerations for successfully implementing a provider life cycle management solution for a payer using Pega BPM and Robotics process Automation for higher performance and Returns on Investment (RoI).
Case management features of Pega:
Case management feature is the foundation for a successful PLM implementation. This feature was introduced in Pega version 6.x, and evolved into a very mature state in the latest 7.x versions of Pega. The Case designer screen offers many features OOTB to create a case, design the stages and life cycle, and establish the parent-child relationship among the cases. A case will have multiple stages which in turn is composed of multiple steps. Each step can call one or more workflow. In a PLM solution, typically every provider load there will be a bare minimum of a contract case, under which multiple provider cases will be added. Also, for every provider 2 business functions are essential – Credentialing and Configuration or Provision of provider in the claims systems. So typical case structure will be as below:
Overall, the case life-cycle will be envisioned as:
Case management comes with default SLA configuration which can be applied at the Case level itself or at the stage level or at the individual workflow level.
Workflow Capabilities of Pega:
As a BPM software, Pega offers Robust workflow capabilities. In a typical PLM lifecycle, the onboarding process is a complex, multilayered process, involving multiple actors. Pega workflow offers variety of Out-of-the-Box capabilities including a variety of smart shape options, option to spawn into multiple processes. All these parallel processes can be also configured to culminate at a common endpoint. Pega also offers the circumstancing feature which would enable the same workflow to behave differently for different contexts such as statewise or provider types etc.
Efficient Data model is the foundation for performance and maintenance of any enterprise application. For PLM implementation, utilizing the data model offered by Pega Healthcare Industry Foundation (HCIF) layer will be the most appropriate. HCIF provides extensive data layer which caters to Provider, Member, Claims etc. using HCIF provided data layer helps in reducing the development time as well.
Robotics for Credentialing:
Process of provider credentialing is mandatory in a PLM lifecycle and it is a heavily manual process. It involves verifying multiple verification sources to establish the education, prior experience and malpractice information about the provider. Pega robotics platform – OpenSpan can do all these sequential tasks without any manual intervention and efforts. OpenSpan can automatically crawl to various verification sources to check for the provider record , gather the information and if needed take screenshots as well. If there is a malpractice record against any provider OpenSpan can also take the necessary decision such as routing for manual review or rejecting the case. Extensive use of OpenSpan RPA in every possible way can result in huge Returns on Investment (RoI)
Reporting and Dashboards:
For an Enterprise application, reporting and Dashboards are indispensable assets to measure performance, TAT (Turn Around Time) of the process and employees. Pega provides a very efficient, intuitive reporting framework which can help in depicting the exact state of the application. There are a variety of graph options available OOTB. In the latest version of Pega, end users can configure their dashboards.
In addition to the above mentioned features and along with an ocean of OOTB features in Pega 7 platform, it is the quintessential software to build an efficient, scalable PLM solution for process improvements and achieving high Returns on Investment (RoI).