How one health insurer is using RPA to help automate intelligent workflows

Business agility is critical to organizational success. Nothing made this more apparent than the COVID-19 pandemic, which forced organizations to reimagine the way they do business to ensure they could rapidly respond to market changes while continuing to meet the needs of those they serve.

Healthfirst, New York’s largest not-for-profit health insurer, was no exception. Serving 1.6 million members through partnerships with 40,000 providers, the company’s processes were pressure-tested in 2020. The volatility of the situation – the upheaval for its members, providers, sponsor hospitals, and staff – and real-time regulatory changes, meant getting work done quickly and accurately was more important than ever.

“It required a resilient platform,” explained C.J. Brexel, vice president of application development at Healthfirst. “And for us, operationally, [the pandemic] was a non-event [because] Pega is flexible. We were able to auto-enroll over 200,000 additional members during the emergency and quickly get them access to services.”

Using the Pega Platform™, Healthfirst transformed many of its core administrative functions, including enrollment, claims, authorizations, payments, and provider lifecycle management.

To make things easier for providers, Pega enabled Healthfirst staff with the agility needed to quickly enroll new providers. The solution includes the use of Pega Robotic Process Automation (RPA) to automate 75% of updates.

Putting intelligent automation to work to build fast and scale

But that’s just the beginning of its provider solution. Healthfirst also extended its pre-authorization Pega application used by care management staff to providers by mashing it up directly into their provider portal. Now, providers can digitally submit a pre-authorization for services, and, in many instances, they can receive a decision immediately. Forty percent of the process is now fully automated, providing an improved experience for those who partner with the health insurer.

For C.J., it’s these types of results that confirm why leveraging the Pega Platform for low-code automation was a good decision.

“There’s tremendous value that business agility brings,” he explained. “Before Pega, we were trapped in legacy monoliths that had rules embedded in decades of code. Change used to be hard for us, but now with Pega, we are able to adapt to change more quickly.”

Providing organizations with that type of business agility is what differentiates Pega. Like Healthfirst, many businesses take advantage of Pega’s intelligent automation capabilities to drive true digital transformation.

For some, that may mean starting with RPA to bridge legacy systems and accomplish short-term goals. However, RPA isn’t the only tool to consider. Your path toward transformation should involve the appropriate tools that not only connect systems but infuse intelligence and revitalize processes from the ground up. That may involve AI, ML, task mining, chatbots and intelligent virtual assistants, work orchestration, and more. The goal is to use the right technologies to solve business needs quickly without the need for major rework in the future.

RPA and intelligent automation tools are helping build and deliver superior end-to-end digital experiences

It was this vision for RPA and intelligent automation that earned Pega its Visionary position in Gartner’s Magic Quadrant™ for Robotic Process Automation 2021. Out of 18 vendors, Pega ranked #1 in completeness of vision as a market innovator.

Highlighted strengths in the report include Pega’s feature-rich platform that enables customers looking beyond RPA to event-driven, end-to-end automation as well a variety of robotic- and platform-based innovations, such as X-ray Vision and Process Fabric.

These are the types of capabilities organizations have come to depend on, much like Healthfirst does. Not only has the health insurer transformed experiences for its providers, it has also leveraged the Pega Platform to handle one of the most complex healthcare processes – claims processing.

For claims, Healthfirst uses the intelligent automation capabilities offered by Pega to identify issues with claims and repair them before processing begins. That includes the use of logic for things like identifying impacted claims for retroactive enrollment and matching authorizations to claims as well as event-based processing to trigger editing steps, case management capabilities, and baked-in process transparency.

“That’s a big deal for us,” Brexel said. “We process over 30 million claims a year, and with Pega, we’ve been able to increase our first-pass rate all the way up to 92%.”

In a world of uncertainty, that’s the type of business agility organizations need today. The ability to scale digital transformation across the enterprise as needed – all while choosing the right technologies for the job, whether that’s RPA, AI, workflow, or a mix of all three.

“COVID drove a lot of change in our operations,” Brexel explained, “but we have demonstrated that with the Pega Platform, we are ready for it.”