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Presentation Title Presentation Title Second Line Author Title Improving Care Management at Anthem With Pega CRM ©2016 Pegasystems Inc. Lisa Ledford-Crissey Vice President, Anthem Shally Pannikode Staff Vice President, Anthem
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Page 1: Presentation Title Presentation Title Improving Care ... · Presentation Title Presentation Title Second Line Author Title Improving Care Management at Anthem With Pega CRM ©2016

Presentation Title Presentation Title Second Line

AuthorTitle

Improving Care Management at Anthem With Pega CRM

©2016 Pegasystems Inc.

Lisa Ledford-CrisseyVice President, AnthemShally PannikodeStaff Vice President, Anthem

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Our Speakers for Today

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Lisa Ledford-Crissey, Vice President

3

Lisa is Vice President of Care Management Operations Solutions for Anthem. She is a provenleader in the field of managed care nursing and informatics with various management rolesspanning 18+ years both in clinical operations and technology. As part of the Corporate HealthCare Management team, Lisa is responsible for Enterprise-wide strategy, development andimplementation of clinical applications supporting Medical Management operations and Cost ofCare strategies for Commercial, Medicaid and Medicare lines of business.

Lisa has successfully led several large-scale care management platform development andimplementation efforts over the years, including leading the industry on case management mobilecapabilities and deployment of a Longitudinal Patient Record.

Currently, Lisa is leading the clinical business team in the development of Anthem CareManagement Solutions; introducing transformational change by reducing four legacy systems intoa single, integrated care management platform for all lines of business that will enhanceAnthem’s ability to engage and enable Providers to better achieve high quality memberoutcomes.

Contact Info

[email protected]

Care Management Operational Solutions, Anthem

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Shalima Pannikode, Staff Vice President

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Shalima (Shally) is currently working as Staff Vice President and IT Owner for Anthem’sMedical Care Management (MCM) technical division. A veteran of 18+ years of ITexperience, Shally has a proven track record of successfully leading and deliveringinnovative solutions in extremely challenging environments with a financial accountability of$100M+ and a large IT organization globally dispersed associates

Shally is a technology evangelist and has a proven record for identifying solutions to addressdigital health care needs. She is one of the ‘most promising’ technology leaders of Anthem,who strongly believes in bringing superlative customer value and thought leadership whilebuilding ‘NextGen Care Management Solutions’using latest technologies.

Contact Info

[email protected]

Medical Care Management, Anthem

Page 5: Presentation Title Presentation Title Improving Care ... · Presentation Title Presentation Title Second Line Author Title Improving Care Management at Anthem With Pega CRM ©2016

Discussion Points• Introducing Anthem and ACMS

• All About PEGA CRM @ Anthem

• User Journey Until Now

• What Lies Ahead: The Future Roadmap

• Discussion and Conclusion

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Introducing Anthem and Anthem’s Care

Management Solutions (ACMS)

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Anthem - A Brief Overview

7

Key Subsidiaries

1 in 9 Americans38.7 Million

Total medical members in affiliated health plans

Over 72 MillionTotal lives served

Affordable Access to Quality Care

93%of Physicians

96%of Hospitals

Member access through BCBSA’s national BlueCard

PPO program

Measures & Metrics

$226BBenefits paid

721MClaims processed

62MService Calls

$78.4BTotal Ops revenue

$165Mon grants to local & national initiatives since 2000

$5.6Min community impact through associate programs

$41.5MActive dollars in local communities

Q4, 2015 Data

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Anthem’s Medical Care Management Solutions (ACMS)

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Utilization Management

Case Management

Disease Management

Anthem Care Management Solution (ACMS)

Case and DiseaseManagement

Local Pod-Based Operations

Inpatient / Concurrent Reviews

Local Pod-Based Operations

Outpatient, Specialized and Post

Service ReviewsCentralized Operations

Gaps in Care / Member Outreach

Clinical Rule Based Interventions

Care Management Programs

New Service Development

Integrated Care Management

Integrated IT PlatformIntegrated Provider Interaction Model

Workflow / Core ProcessingIntelligent Decision Support & Analytics

Ecosystem and Data Exchange

Data Analytics

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Our Focus at ACMS

9

IMPROVE EFFICIENCY

Rapidly identify pertinent clinical information in UM requests

Automated access to clinical data, benefits, eligibility, etc.

Better collaboration mechanisms to obtain missing clinical information

Faster approval for cases that require manual intervention

Promote proactive health management and quality

Reduce unnecessary utilization and admissions

Improve outcomes through better Care Management

Identify gaps in care and intervention opportunities

v

Medical Cost Savings

IMPROVE QUALITY

Operational Cost Savings

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Challenges Prior to Pega CRM

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Lack of Automation in IVR due to decentralized data storage

High degree of manual intervention at decision points

Highly time consuming activity as users needed to navigate through multiple applications to check eligibility, benefits, network, precertification etc.

Onboarding and Training challenges as the user needs to be trained in multiple applications and

workflows

High error rates due to multiple workflows for users

within the same region

Inability to capture data and timestamp of various

stages of a fast paced transaction processing

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Anthem Team Made it Happen

11

Discussion with

Business Stakeholders

Evaluate Buy vs.

Build Options

Initiate Due

Diligence

• Review initiatives• Determine strategy• Planning sessions

• Socialize the idea of a ‘new’ platform• Gather key inputs from

key stakeholders

• Initiate project planning activities• Implement the project• Review ROI and business benefits• Plan for further enhancements

• Deep dive discussion• Evaluation of ‘Build’ vs. ‘Buy’

vs. ‘Hybrid’ Framework• Calculate ROI and create a

business case

• Evaluate Pega CRM• Complete feasibility analysis• Obtain approval for project execution

Cost

Scalable

UX

Evaluate Pega CRM

ImplementPega CRM

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All About Pega CRM @ Anthem

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Pega’s Unified Platform Empowers Anthem’s View

13

Integration with IVR to pre-populate all caller information into core application

Market-specific customized business process flows to ensure standardized workflows

Real-time eligibility check using Pega Rules Process Commander (PRPC) architecture

Capture and Review of key call metrics (# of calls, TAT, # of transfers, reason for the call etc.) using Pega BIX

Enhanced change management process using highly flexible PRPC architecture

Improved reporting and dashboard capability with comprehensive performance management, reporting, and self-documentation capabilities

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Technology Stack: Pega CRM at Anthem

14

Reporting Database

Pega Rules Process Commander (PRPC)

Pega Customer Service Healthcare Suite

Pega Customer Service Suite (Pega Call)

Pega Healthcare Industry Foundation

UM Rules Framework

UM Implementation Layer

Pega’s Business Intelligence Exchange (BIX )

Incoming call (IVR) gets

validated & routed automatically to

CSR by Pega Call

Pega CRM Suite

Anthem-Specific Configuration LayerPega CRM interacts with other internal & external applications via a SOA based architecture

Pega CRM interacts with legacy WMDS applications via stored procedures

Future enhancements using Anthem-specific UM Rules Framework

Future Enhancement: Install and use Pega Autonomic

Event Services (AES) for enhanced application monitoring capabilities

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Implementation Methodology & IT Challenges

15

Agile & collaborative scrum approach

Iterative approach

Complexity in various system integrations with Pega CRM (both internal andeExternal)

Extensions needed for 270 / 278 HIPAA transactions in PEGA CRM

Aligning deployment automation (DevOps) with Pega7

Methodologies Challenges

Limited availability of Pegacertified/trained resources to execute the project

Solutions & Best Practices

Parallel development approach followed to identify key technical challenges

early during execution phase

Close collaboration with Pegateam to get timely tech support

Re-alignment of skilled resources

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Time to Reap the Benefits

16

Single application for users to check eligibility, benefits, Pre-certs etc.

Automated workflow management system to select

appropriate WF for a case

Single, consistent user interface for

ease of navigation

Enhanced reporting capabilities; now

tracking key metrics

Automated decision making abilities

Immediate Benefits

Checkpoints for critical and error prone areas to improve accuracy

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Time to Reap the Benefits

17

Long Term Benefits

Streamlined, shorter training for new joinees

Further opportunities for

automation due to integrated CRM

platform

Strategic reporting and

dashboard capabilities for

senior management

Continuous productivity

improvement due to accessible case

data

Considerable cost savings in terms of dollar amount

Page 18: Presentation Title Presentation Title Improving Care ... · Presentation Title Presentation Title Second Line Author Title Improving Care Management at Anthem With Pega CRM ©2016

User Journey Until Now

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Testimonials From Our Users

19

Kevin ShafferClinical Systems and Reporting Lead

Florida, USA

Bridget ArdeleanCentral Region Intake Manager

Indianapolis, USA

“Pega CRM has given us tremendous visibility into our transaction mix and productivity. We are now able to accurately identify exactly what types of

interactions we have, how many, and how long each takes, which gave us the capability to create a new robust report sets. This also allows for much more

detailed analysis, as well as improved staffing and workload evaluation.”

“During pilot testing (SEP 2015), a few of my team members, worked with PEGA CRM and they fell in love with all that it had to offer. The automation features within CRM is what they loved the most. The team was excited that the system would return benefits, eligibility, and pre-cert/pre-d decisions without them having to go outside the system to research for it. Since then, we have expanded to multiple regions and end- user feedback has been consistent around the automation. I can see the visible improvement in terms of individual productivity and TAT for each of the transactions.”

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Testimonials From Our Users

20

Shannon DayCentral Local Intake

Team LeadIndianapolis, USA

Glendale LiganCentral Local Intake SME

Cebu, Philippines

“PEGA CRM is an easy-to-use system with advanced technology to eliminate manual processes and potential

[human] errors. The UI design is easy to navigate and allows us to be ‘accountable’, ‘innovative’, ‘trustworthy’, ‘easy to do

business with’ , and ‘caring’. It truly reflects Anthem’s core values. A single platform to manage constant change and

help reduce human error. Every single transaction in PEGA is accounted for, which we never had with prior systems.”

“As a SME, I realized that the key differentiator of the PEGA CRM tool is that it can do backend validation for a requested medical service and recommends if a pre-authorization can be issued or not. This improves accuracy and fast- tracks the process by reducing manual steps by quite an extent. Besides that, the tool has greatly helped in reducing redundancies in managing case related documents as all documents are available in the tool itself.”

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Testimonials from End Users

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Emerliza MantalabaCentral Local Intake Team Member

Cebu, Philippines

Ashwin KumarCentral Intake Team Member

Bangalore, India

“PEGA CRM has an extremely easy screen design, which helped me in learning and adopting the tool in no time. With

the ease of navigation, automated data validation, and built-in error prompting, CRM has helped me in reducing

manual errors and improving my productivity. Thanks to the management for bringing this valuable tool for our use.

I hope I can utilize the tool to its fullest potential.”

“PEGA CRM has been a pretty powerful tool with loads of automation features built into it. It does the basic data validation of an incoming transaction and provides key insight around handling a region-specific case. With the built-in workflow engine, we can now track our work, identify ‘aging of transactions’, and prioritize a request all within the tool itself. It has been an amazing experience so far.”

Page 22: Presentation Title Presentation Title Improving Care ... · Presentation Title Presentation Title Second Line Author Title Improving Care Management at Anthem With Pega CRM ©2016

What Lies Ahead: The Future Roadmap

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What Lies Ahead: The Future Road Map

23

Close Collaboration Strategic Partnership

Roll out 25 additional market segment

Touch 72 million

more lives

Collaborative cost savings

Continuous Improvement in

productivity by 8–10%

Continuous system enhancements to improve user experience

Our Partnership Our Approach Our Goal

Page 24: Presentation Title Presentation Title Improving Care ... · Presentation Title Presentation Title Second Line Author Title Improving Care Management at Anthem With Pega CRM ©2016

Discussion and Conclusion

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THANK YOU


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