Case study
Molina Healthcare transforms appeals and grievances
See how they used Pega to transform a legacy platform.
saved annually
reduction in case resolution time
hours saved per year
The Business Issue
Molina Healthcare is a Fortune 200 company that provides Medicaid, Medicare, and marketplace health insurance coverage to more than 4.5 million individuals across 19 U.S. states. As membership has grown over the years, it has become critical that Molina transition away from homegrown applications to a scalable, sustainable platform to meet business needs.
Specifically in the appeals and grievances processes, there was room for improvement. The existing in-house application was dated, inefficient, and not scalable. It lacked standardization – with each health plan following their own processes – making it difficult for Molina to integrate with other systems in its portfolio.
These technical issues led to business problems, including overturned appeals, duplicate denials, and thousands of hours spent on manual data entry. Molina saw an opportunity for process improvement and automation, better correspondence with members, and integration with core systems.
The Solution
With consultation from Cognizant, Molina completed a thorough analysis on market-leading products, and ultimately chose Pega for its platform transformation. This decision was based on Pega’s ability to scale fast, and our low-code workflow development and flexible integration. The ability to host Pega on Azure was an additional positive point for the Molina team.
They implemented Pega’s Appeals and Grievances, a robust solution built on the Pega Platform™, which leverages case management, workflow automation, and real-time analytics capabilities to automate and optimize the end-to-end management of appeals and grievances.
The Results
After piloting the new platform with two of its health plans, Molina began to onboard additional health plans every two months. So far, the company has seen the following benefits:
- $3 million saved annually
- 30% reduction in case resolution time
- 60,000 hours per year saved from automation of outbound correspondence
- New plan onboarding time reduced to weeks from months
- Standardized workflows across all health plans while retaining the agility to accommodate geographic and contractual variations
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"After starting our transformation to Pega, we now have 7,000 active users, using three tier-one platforms that were built and deployed in Pega. We are also consolidating different business processes and workflows into Pega to bring [users a] seamless experience by enabling integration between different applications that we use here today."