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  • Presentation Title Presentation Title Second Line


    Improving Care Management at Anthem With Pega CRM

    2016 Pegasystems Inc.

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

  • Our Speakers for Today

  • Lisa Ledford-Crissey, Vice President


    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 enhanceAnthems ability to engage and enable Providers to better achieve high quality memberoutcomes.

    Contact Info

    [email protected]

    Care Management Operational Solutions, Anthem

  • Shalima Pannikode, Staff Vice President


    Shalima (Shally) is currently working as Staff Vice President and IT Owner for AnthemsMedical 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 Solutionsusing latest technologies.

    Contact Info

    [email protected]

    Medical Care Management, Anthem

  • Discussion Points Introducing Anthem and ACMS

    All About PEGA CRM @ Anthem

    User Journey Until Now

    What Lies Ahead: The Future Roadmap

    Discussion and Conclusion

  • Introducing Anthem and Anthems Care

    Management Solutions (ACMS)

  • Anthem - A Brief Overview


    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 BCBSAs 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

  • Anthems Medical Care Management Solutions (ACMS)


    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

  • Our Focus at ACMS



    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


    Medical Cost Savings


    Operational Cost Savings

  • Challenges Prior to Pega CRM


    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


    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

  • Anthem Team Made it Happen


    Discussion with

    Business Stakeholders

    Evaluate Buy vs.

    Build Options

    Initiate Due


    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




    Evaluate Pega CRM

    ImplementPega CRM

  • All About Pega CRM @ Anthem

  • Pegas Unified Platform Empowers Anthems View


    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

  • Technology Stack: Pega CRM at Anthem


    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

    Pegas 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

  • Implementation Methodology & IT Challenges


    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

  • Time to Reap the Benefits


    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

  • Time to Reap the Benefits


    Long Term Benefits

    Streamlined, shorter training for new joinees

    Further opportunities for

    automation due to integrated CRM


    Strategic reporting and

    dashboard capabilities for

    senior management

    Continuous productivity

    improvement due to accessible case


    Considerable cost savings in terms of dollar amount

  • User Journey Until Now

  • Testimonials From Our Users


    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.

  • Testimonials From Our Users


    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 Anthems 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.

  • Testimonials from End Users


    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.

  • What Lies Ahead: The Future Roadmap

  • What Lies Ahead: The Future Road Map


    Close Collaboration Strategic Partnership

    Roll out 25 additional market segment

    Touch 72 million

    more lives

    Collaborative cost savings

    Continuous Improvement in

    productivity by 810%

    Continuous system enhancements to improve user experience

    Our Partnership Our Approach Our Goal

  • Discussion and Conclusion


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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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