Healthfirst enhances efficiency and care with Pega

The Business Issue

Healthfirst, a leading not-for-profit health insurance company, encountered substantial challenges in managing its provider lifecycle. The existing manual and fragmented processes for provider onboarding and credentialing led to significant delays, inefficiencies, and a lack of transparency.

Healthfirst primarily supports Medicare and Medicaid programs, serving nearly 2 million members across New York City and its neighboring counties. The inefficiencies and delays in their provider onboarding process not only hindered operational efficiency but also impacted the quality of care provided to their members.

The urgency for a streamlined process became even more critical during the peak of the COVID-19 pandemic, as the need to rapidly onboard temporary healthcare staff surged. By leveraging Pega's advanced automation and workflow capabilities, Healthfirst aimed to transform their onboarding process, ensuring timely and efficient integration of healthcare providers, ultimately enhancing service delivery and patient care in a sector where time and accuracy are paramount.

The Solution

Partnering with Virtusa, a global leader in IT and transformation services, Healthfirst leveraged the Pega Platform™ to implement a comprehensive Provider Lifecycle Management (PLM) solution. This initiative utilized Virtusa’s innovative PLM accelerator, built on Pega Infinity 24, to automate and optimize every step of the provider lifecycle. The solution included:

• Automated credentialing: By integrating with CAQH and employing robotic process automation (RPA) for primary source verifications, Healthfirst reduced credentialing times from three months to three weeks. This acceleration is crucial in the healthcare sector, where timely credentialing ensures that qualified providers can start delivering care sooner, directly impacting patient access to services.
• Streamlined onboarding: The implementation of a paperless contracting process, enhanced by Pega’s digital case management and DocuSign integration, facilitated faster provider onboarding. This efficiency not only reduces administrative burdens but also ensures that new providers can be integrated into the network swiftly, maintaining continuity of care and improving patient outcomes.
• Enhanced data management: Improved data verification and transparency through centralized workflow management significantly reduced the complexity of handling provider data. Accurate and accessible data is vital for compliance, reporting, and operational efficiency, ultimately leading to better decision-making and enhanced service delivery.
• Innovative use of generative AI: The PLM solution incorporated generative AI capabilities for contract generation, further speeding up the contracting phase. This innovation not only reduces the time and effort required to create contracts but also minimizes errors, ensuring that agreements are accurate and compliant with regulatory standards.

By addressing these critical areas, Healthfirst's PLM solution not only streamlined operations but also enhanced the overall quality of care provided to its members. In an industry where efficiency, accuracy, and speed are paramount, these improvements have a profound impact on both provider satisfaction and patient health outcomes.

The Results

The transformation journey, underpinned by Pega's robust platform and Virtusa's expertise, delivered significant operational improvements and business value for Healthfirst:

• Reduced onboarding time: Provider onboarding times were reduced from an average of 90 days to three weeks – a 76% decrease in onboarding time that ensures that Healthfirst could meet the urgent healthcare needs of its members without delay.
• Improved transparency and efficiency: The centralized system provides full visibility into the provider lifecycle, enabling proactive management and reducing escalations. Service level agreements (SLAs) ensure accountability and timeliness, fostering a more efficient and transparent operational environment.
• Enhanced provider and member satisfaction: Faster onboarding and credentialing processes significantly improved Healthfirst's ability to deliver timely care. The integration of automated credentialing and streamlined onboarding processes not only reduced administrative burdens but also enhanced satisfaction among providers and members alike – ensuring that patients receive care from qualified providers more quickly.
• Recognition and growth: The innovative transformation was recognized by the New York Times, highlighting Healthfirst’s agility and responsiveness during the pandemic. Healthfirst continues to grow, reaching approximately $18 billion in revenue and expanding its workforce to better serve its members. This recognition underscores the success of the transformation and its impact on the healthcare sector.