Case Study
Molina Healthcare redefines member and clinician experience
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Saved over $40M annually through increased efficiency and decreased specialization
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Improved end-to-end process for authorizations with automated intake and routing
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Improved user experience through single application and eliminated swivel chair
“The benefit of Pega? No more swivel chair. It's one system. Clinicians don't have to go into two. Pega's talking to both of them.”
The Business Issue
With a special commitment to underserved populations and low-income individuals, Molina Healthcare operates in 22 states across the U.S. and serves more than five million members primarily through Medicaid.
But siloed departments and a lack of standardization made serving its members difficult. The company lacked automation and had no centralized way to determine benefit coverage for members. On the back end, users required multiple windows to complete a task. Communication happened via email while spreadsheets were used to manage projects. A lack of real-time reporting or dashboards added to the obscurity.
This prompted Molina Healthcare to seek a transformative solution that would enable it to automate and digitize its operations.
The Solution
Recognizing the need for a comprehensive solution to address its complex system landscape and manual processes, the company built the Molina Enterprise framework with Pega.
The implementation began with a bottom-up approach, starting with the appeals and grievances process. Once that went into production, Molina Healthcare shifted its focus to utilization management, leveraging Pega’s out-of-the-box functionality to rapidly deliver. Integration was a key aspect of the solution, ensuring seamless communication with other systems and enabling the generation and receipt of letters and faxes.
Using Pega, Molina Healthcare eliminated swivel chair and consolidated its workflows into a single system, providing clinicians with a more efficient and user-friendly experience. The platform's rules engine allows for easy traceability and compliance, enhancing auditability and decision-making.
Throughout the implementation process, Molina Healthcare followed best practices such as a digital-first approach, leveraging out-of-the-box functionality, reducing cycle times, and ensuring adherence to design patterns and naming conventions. The collaboration between business and IT, along with strong governance and change management, played a vital role in the implementation’s success.
The Results
One of the key results achieved was the significant reduction in front-end fax processing time, saving between six to nine minutes per fax. With approximately five million faxes processed annually, this resulted in substantial efficiency gains.
Other results at-a-glance:
- Less than three minutes to build authorizations
- 95% of transactions completed in real time
- More than $40M in annual savings through increased efficiency and decreased specialization
- Reduction of up to five minutes in processing times for nurses, further improving productivity
- Improved end-to-end process for authorizations with automated intake and routing
- Improved user experience through single application and eliminated swivel chair
- Enterprise-level reporting with dashboards to allow greater visibility