Pegasystems Helps Payers Meet Recent U.S. Government Healthcare Cost-Cutting Mandates
New Pega CRM solution for the healthcare industry enables healthcare organizations to stay ahead of reform
Pegasystems Inc., the leader in business process management (BPM) solutions, recently unveiled a significant upgrade to its customer relationship management (CRM) offering for healthcare organizations. With Pega's Customer Process Manager for Healthcare, organizations can deliver on new reform-mandated cost efficiencies while also providing superior customer service consistently across all communication channels.
New mandates include medical loss ratio (MLR) requirements and other reform-based cost constraints that are forcing healthcare payers to produce dramatic operational efficiencies and shift their cost curves. New cost limits impact payers at the same time that customer service is becoming the predominant market differentiator and transactional volumes are set to explode.
The anticipated spikes in healthcare transactions, including exponential increases in service inquiries, claims, bills, and authorizations, will be caused by 35 million new previously uninsured members being added to the insurance market. Predominantly from Medicaid and Medicare segments, many of these new members will be associated with high-utilization patterns. Exploding volumes make it more challenging to ensure quality and contain costs. As employer-sponsored coverage shrinks by 13 percent, more than half of the market will now be in a position to switch plans due to inferior customer service .
Pega is a recognized industry leader in CRM, and its healthcare solutions enable organizations to automate expensive processes and provide a personalized and responsive customer experience consistently across all channels, lines of business, and service needs. Payers using Pega have reported up to a 30-percent increase in first call resolution, 20-percent greater elimination of duplicate calls, and a 40-percent improvement in throughput for service requests.
These solutions, now in use on more than 20,000 healthcare desktops, deliver cost savings by providing complete automation for common healthcare service inquiries. Flexible and adaptable rules, built into each process, provide dynamic work management where processes automatically adjust to account for new information and criteria. Integrated service level processing ensures that service interaction handling aligns directly with bottom line goals.
To see the solution in action, please visit Pega at Booth #2581 at HIMSS, taking place at the Orange County Convention Center, Orlando, Fla.
Pega's solutions are widely used by major healthcare organizations including seven of the eight largest US health plans, two of the four largest pharmacy benefit managers, several leading healthcare delivery systems, and US government agencies at the state and federal level. Healthcare transactions for more than one of every two Americans, including members from over 60 percent of the Blues network, are processed with Pega technology.
Quotes & Commentary:
Joanne Galimi, Research VP, Gartner (from report titled "Key Issues for Healthcare Payers, 2011")
"The customer experience is reaching a crunch point for many healthcare payers. Customer churn due to one poor customer experience is increasing. Customer expectations continue to rise, and customers are increasingly willing to share their poor experiences online. At the same time, more payer executives believe that the customer experience will make their organizations unique, leading them to try to differentiate themselves with a superior experience."
Janice Young, Program Director, IDC Health Insights
"Healthcare payers' ability to meet reform medical loss ratio, cost control, and clinical effectiveness targets requires better customer partnership and retention."
Elizabeth Hart, Principal, Healthcare Solutions at Pegasystems
"Virtually every other industry is ahead of healthcare in providing consumer-focused capabilities and superior customer service. Reform is moving healthcare firmly to the consumer market and it's crucial for healthcare payers to leverage advanced technology in order to succeed there. Pega's proven healthcare-specific solutions efficiently deliver enhanced service capabilities, driving down costs while improving customer satisfaction and retention. Plus, the solutions utilize Pega's Build for Change technology and are easily modified to respond to on-going changes in the healthcare market."
Supporting Resources:
For more information, visit http://pega.com/resources/customer-process-manager-for-member-services and http://pega.com/resources/customer-process-manager-for-provider-services.
To read more about Pega healthcare customers' successes, visit: http://www.pega.com/solutions/by-industry/healthcare/customer-success
For more information on Pega's healthcare-targeted solutions, visit: http://www.pega.com/industries/healthcare/bpm-for-healthcare.asp and http://www.pega.com/industries/healthcare/frameworks.asp
To hear more about the CPM-HC solutions' impact on cost and service, please attend Pega's breakout session at the Gartner Customer 360 Summit on March 31, at the JW Marriott in Los Angeles, Calif. The session will feature Mark Knutson, VP, Customer Service at Prescription Solutions, a UnitedHealth Group Company.
About Pegasystems
Pegasystems, the leader in business process management solutions and a leading provider of CRM solutions, helps organizations enhance customer loyalty, generate new business, and improve productivity. Our patented Build for Change technology speeds the delivery of critical business solutions by directly capturing business objectives and eliminating manual programming. Pegasystems enables clients to quickly adapt to changing business conditions in order to outperform the competition. For more information, visit www.pega.com.
SOURCE: Pegasystems Inc.