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Automating the Claims Reporting System of an Insurance Company

Automating the Claims Reporting System of an Insurance Company

Client: One of the largest global financial services companies with business lines in life, vehicle, travel, and health. It is also amongst the top health insurance brands on the basis of customer loyalty.

Business Problem: The client’s legacy claim storage system was unable to show linking between multiple claims. This lack of linking between claims caused inaccurate reporting and created the need for an involved and cumbersome manual process to cross-reference related claims to create accurate reports.

Our Solution: To meet this challenge, an application was built on Pega 7 that created linkages between related claims. With this solution in place, the reporting process was streamlined and improved by removing the need for manual human interaction. This application also monitored the existing claim storage system, and automatically created files and stored them in the system of record (SOR) whenever a configurable threshold limit for files was reached.

Benefits: The solution helped in developing an efficient and accurate reporting system that gave a better view on payments and loss. Replacing existing Excel spreadsheets with an automated claims processing systems led to better auditing and tracking.

Improving the overall efficiency for a Pharmacy Benefit Company

Improving the overall efficiency for a Pharmacy Benefit Company

Client: One of the largest pharmacy benefit management organizations (PBM) providing pharmacy benefit management services including network-pharmacy claims processing, industry-leading home delivery and specialty pharmacy services.

Business Problem: The client wanted to drastically improve the way services were managed across the enterprise. The key challenge was replacing a manual processing approach that was error-prone, time intensive and frustrating to the staff. People had to call a variety of numbers to make enquiries. Processing was often paper-driven and disjointed which required several hand-offs between teams.

Our Solution: To meet this challenge, the application was built using the Pega Customer Service platform which provided a seamless transition across communication channels without losing context.

Paper-driven processing was first enhanced by integrating Pega with Kofax. The inbound fax would generate cases that would kick off a data entry step. Bar code information would be used to display the appropriate form in Pega. The system would then leverage the data entered to interpret the request and distribute work to the appropriate teams, thus limiting the number of hand-offs.

Reuse was strongly emphasized throughout the project which allowed us to leverage the same processing logic, validation, interfaces and UI components when exposing forms to the web channel. The Pega Web Mashup feature was used to embed the Pega forms on the corporate website. This allowed the customer to perform the data entry step on the web and kick off the creation of the case upon submission. Validation was applied before the case was created, allowing the customer to make the necessary corrections.

Benefits to Client: The solution enabled process automation, straight-through processing while increasing Customer Satisfaction, increasing Customer Retention and decreasing training time of customer service representatives.

Building a Claims processing solution on Pega Smart Claims Engine

Building a Claims processing solution on Pega Smart Claims Engine

Client: A global health services organization, with insurance subsidiaries that are major providers of dental, medical, Medicaid and Medicare plans. The organization provides health insurance plans to individuals, and through governmental and non-governmental organizations, unions and other associations

Business Problem: With the drastic and continuous changes to Healthcare in the US, antiquated claims adjudication systems in place are not able to meet the needs of today’s Healthcare Payers. In addition, a main concern in new claims systems is flexibility and configurability, it is imperative that if an issue is identified with business rules, claim edits or other processes, that the issue can be resolved without substantial time and effort. Configurability be business users without the need for dedicated IT staff is of the utmost importance.

Serendebyte Solution: Serendebyte played a key role in the definition and delivery of the Pega Smart Claims Engine, including in soliciting requirements, user story creation and grooming, sizing initiatives and leading Pega DCO sessions. With focus 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 though specialized users are able to make changes, these changes would not be able to negatively impact system performance or cause major exceptions that would cause claims to be incorrectly adjudicated.

BPM Wrapper on Predictive Analytics Engine

BPM Wrapper on Predictive Analytics Engine

Client: The client provides prescriptive analytics solutions to its customers across a diverse set of industries. Their solution can be used by end customers to enhance their decisioning capabilities as well as partners who can embed the client’s solutions into their strategy, operational planning and analytics solution offerings.

Business Problem: The client’s prescriptive analytics solution is extremely robust with a very powerful optimization engine at its core. However, the client as well as its customers felt that the optimization engine was not very user friendly. Any customization work that had to be done for a particular industry required making changes under the covers of the product. This was not only time consuming but also expensive since this required highly skilled mathematicians and optimization experts. Additionally, the existing solution did not provide visibility into key operational metrics. The client was losing a lot of business because no organization wanted to spend over six months to customize an analytics solution for their needs.

Serendebyte Solution: Serendebyte proposed and built a highly user centric layer on top of the client’s optimization engine. This layer was built using IBM BPM 8.5 Advanced Edition. This solution included user friendly work flows, reporting dashboard as well as a templatized platform for users to build vertical solutions on top of the client’s optimization engine. Serendebyte built this solution over a six- month period with a 100% offshore team of 5 architects and developers. With the help of this solution, the client has now reduced the time to build customized vertical solutions on top of their core platform from months to days.