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© 2017, COGNIZANT© 2017, COGNIZANT
THE DIGITAL TRANSFORMATION JOURNEY OF CAREFIRST BLUE CROSS BLUE SHIELDHarish Dwarkanhalli, VP & Global Delivery Head – BPM and Integration, Cognizant Jagdish Singla, Sr. Manager – Enrollment and Billing, CareFirst BCBSAlok Mandal, Principal Architect – BPM and Integration, Cognizant
© 2017, COGNIZANT© 2017, COGNIZANT
Founded in 1994 (CTSH, Nasdaq)
Headquarters: Teaneck, NJ100+ Global Delivery Centers
Revenue$13.49B in 2016 (8.6% YoY)
260,200 Employees (Dec 2016)
Revenue MixNA: 78%, Europe: 16%, RoW: 6%
Newsweek’s2015 World Green Rankings
ForbesFast Tech 25
Fortune’sMost Admired Companies Years in a Row
ForbesGlobal 2000
Fortune500
Financial TimesGlobal 500
© 2017, COGNIZANT© 2017, COGNIZANT
Cognizant’s Pega Practice – Longest Running Partner of Pegasystems
Winner of 2017 Partner Excellence Award In Driving Customer Success: Practice Breadth & Depth
Cognizant’s Pega Practice – Longest Running Partner of Pegasystems
17+ years long relationship with Pega
26,000+ Person yrs. of Pega experience
50+ Pega 7.x Upgrades
360⁰ Partnership
13 Pega Partner Awards
Consecutive Awardsincluding Partner excellence
and Innovation
100+Active Pega Customers
1500+ Successful Pega Projects
10+Digital Industry Solutions
30+ Accelerators
2,600 Pega consultants
2350+ Certifiedconsultants
45 CLSAcertifications
Winner of 2017 Partner Excellence Award in Driving Customer Success: Practice Breadth & Depth
© 2017, COGNIZANT© 2017, COGNIZANT
Pega & Cognizant HealthCare Journey: Delivering Benefits Across Value Chain
Onboarding Time for large PBM player50%
Capacity to handle individual application for large Blue500%
Average Call Handling Time for large Payer35%
Productivity per CSR for large Payer24%
30%TAT for Prior Auth for a large Payer28%
Therapies for chronic patients through Gaps-In-Care
66%
50%
Termination time for Physicians for Global Healthcare giant
Rework due to demographic data update
Claims processing per hour for a large Healthcare giant135%
Number of Failed Claims for a large Payer30%
Claims Payment Cycle for a Managed Care Org50%
Claims Processing Cost for a Health Insurance major27%
MIDDLE OFFICE
FRONT OFFICE
BACK OFFICE
© 2017, COGNIZANT
© 2017, COGNIZANT© 2017, COGNIZANT
§ API & Microservices§ Secured data exchange
How Macro Trends Are Reshaping IT imperatives in HealthCare Industry Today
© 2017, COGNIZANT
Implications for Payers The Changing Rules of the Game
Predicted to account for more than half of their business
within five years
68% Providers intend to engage consumers to improve outcomes
§ OMNI-Channel Access§ Social Collaboration§ Big Data Aggregation and Integration
§ Auto-adjudication through Robots § Workflow Optimization§ Care Mgmt. Dashboards
20% Follow up cost reduction using remote health tracking tools
80% Payers and Providers adding capabilities within 12 months
60% Payers and Providers utilizing Electronic Health Record (EHR)
shared across organizations
§ Predictive Analytics§ Flexible Health Plan Configurators§ Patient 360
Value Based Care
Consumerism
Population Health Management
Operational Efficiency Enhancement
Shared Electronic Health Record (EHR)
§ Integrated healthcare ecosystem r§ Decision Hub§ Intelligent Rule based Workflow
Digitization
RPA
APIs
Event Analytics
Cognitive BPM
Pega Driven Digital Transformation Imperatives
© 2017, COGNIZANT© 2017, COGNIZANT
Evolution of Pega as Digital Platform of Choice
MACHINE LEARNING AND AI AUTOMATION
- DECISIONING- COGNITIVE BOTS- SELF HEALING
DIGITIZATION- MOBILE ENABLED SELF SERVICE- HANDLING SOCIAL FEEDS- TREND ANALYSIS- DESKTOP ROBOTIC PA FRAMEWORK
AUTOMATION
PROCESS AUTOMATION
© 2017, COGNIZANT© 2017, COGNIZANT
Cognizant at CareFirst
Sales Quoting
Optimized Business Process~ 15 mins Time to Generate Quote
(reduced from 5 days)
Enrollments
ClaimsGroups | Individual Markets
Reduced Enrollment Fallouts by 75% through SLA Driven WorkFlow Automation
Automated Enrollment | Invoices | 820 Payment Processing | Renewals| Contract Generation | Product Composer
Prior Authorization | Provider Inventory and Credentialing
Legacy Claims Processing
Care Management
OperationsPega Deployment Tool | E-Comm
Automated Claims ProcessAchieved 60% Efficiency
Intelligent Routing & Automation Bringing in $750K of savings / year
Self-Service & Digitization enabling State Compliance (MHCC), CAQH integration
and Direct Authorization Updates
© 2017, COGNIZANT© 2017, COGNIZANT 8
‘Enrollments & Invoices’ at CareFirst, Facets Platform
Enrollments & Invoices
Current Functional Spread Enrollments, Invoices, Payments, Delinquency and
Collections, Escalation Management, Reporting, Reconciliation (PPR, Pre-Audit, RCNO, DRF forms),
Renewals
Transaction Volumes Total Active Enrollments – 800K
340K+ Invoices per monthIntake 20 or more reconciliation files per month
A total of 1 million recon transactionsProcess payment receipts totalling $330M+ per month
Total ID cards processed - 25K per month
Servicing Reach 3 Jurisdictions : DC, MD, VA
Intake from On & Off Exchanges 4 different legal entities served: CFBC, CFMI, GHSMI, FirstCare
Handle 8+ market vendorsTotal brokers serviced: 5K+
5+ Pega AdoptionsAE2, CDR, ERMS, PCC, 820Frameworks utilized: HCIF, AES
Business Units Small/Medium and Individual MarketsSales and MarketingEnrollment and Billing Dept OTS (Operation Technical Support)Mandates, Internal controls
Team and Technology Landscape Current team size: 50Pega’s PRPC, ETL, Oracle, TIBCO, Facets
Facets
© 2017, COGNIZANT© 2017, COGNIZANT
Prior Challenges
Missing Business Interface
• No visibility at batch processing and its status with missing audit
• No ability to track and work discrepancies at enrollments, invoicing, payments and renewals
• Absence of real-time dashboard
Multiple File Formats
• Multiple file types, validation variants and duplicate submissions
• Varied business rules based on jurisdictions, market segments and legal entities
• Track and process delta submissions
Manual Reconciliationand Follow-up
• Huge volume of data across various files for reconciliation
• File aging while at validation process
• Data was reviewed in excel sheets and corrections were made. Huge fines paid due to non-compliance
Data Integrity Issues
• Multiple checks/rule variations dispersed across layers caused data leakage
• Incorrect data at multiple outbound letters
• Missing auto-alerts when inconsistencies at data were found
© 2017, COGNIZANT© 2017, COGNIZANT
Enrollment / Invoice Workstation
• Validations on format of received files
• Correction followed by processing
• Validations on format of received files
• Correction followed by processing
Production Support Command Center
AE Command Center
2016
2016
• Holistic view of payment file process starting from 820 file intake to source system
• Track all groups that have their monthly payment in arrears
Payment Support Command Center
Delinquency Command Center
2016
2016
Transformation Journey
User Inputs
Brokers
Healthcare Exchanges
• Intake file from Exchanges• Pre-Enrollment Processing• Primary Validations• Group Assignment
Automated Enrollment 2012
• Error Handling Capability
TPM Portal 2012
• Renewal Letter Generation• Trigger benefit migration and track active & passive renewals
• Special Enrollment Period related functions
• Group Search, Contract Search and file search
Renewals 2015
• Comparison of Subscriber enrollment data with source system data
• Holistic view of the 834 enrollment transactions
• Capabilities for users to rectify errors
Enrollment Reconciliation 2013
• Posting subscriber payments to enrollment system
• Comparison of subscriber subsidy payments with issuer system and identify discrepancies
• Resolve mismatches and tracking
Payment Reconciliation2014
• Generate Invoices• Automated triaging and monitoring of errors
• Reduce manual dependency of billing / invoice related data and files
Invoice 2017
Enrollment System
© 2017, COGNIZANT© 2017, COGNIZANT
Vision for Enrollments & Invoices
Healthcare Exchanges
User Inputs
Brokers
Enrolment System
Machine Learning Layers
• End to end business rule execution and validations• Data enrichment and compliance checks per HIPAA standards• Process automation and Outbound file processing/generation
1. Generate fall out trends at Enrollment File Comparison
1. Capture intake volume patterns at Enrollments
2. Decision trends to Construct / Generate Business rules
2. Predict volumes by Exchange, Jurisdictions and File types
3. Apply derived business rules to auto fix discrepancies at files
Artificial Intelligence Zero human intervention !!
Cognitive Bots !!
• Identify any incoming enrollment file types. Detect, fix any new / existing errors. • Consume updated files and auto-update Enrollment System• Auto Renewals and letter generation• Machine / Bot communicating with Exchanges and Brokers
Adoption of digital deviceto enable configurations
Trends generationReporting
Intelligent Processing Layers – Omnipresent I
Auto handle socialmedia interactions
Desktop automation at file validations
Automation Layer
Digital Layers
3. Align system assets based on predictions to process files
© 2017, COGNIZANT© 2017, COGNIZANT
T E C H N O L O G Y P I L L A R S
P E G A 7 + O R A C L E + E T L
Technology Transformation
Process
Business Rule
Data Flow
Batch
AU
TOM
ATIO
N
Adaptive Reconciliation
Framework
Electronic Health Record
Mobility
Cyber Security
Agility
DIG
ITA
L
Application Monitoring
Adaptive Recognition
Pattern Recognition
PredictiveAnalytics
MA
CH
INE
LEA
RN
ING
© 2017, COGNIZANT© 2017, COGNIZANT
Adaptive Reconciliation Framework
Established ‘Adaptive Reconciliation Framework’ for quicker adoption to new changes
Up to 85% Reuse
80% Increase
80% $ Saving
© 2017, COGNIZANT© 2017, COGNIZANT
Adaptive Reconciliation Framework
Process Outcome
Business Rules
Intake Processing
Enrollment System(FACETS)
Process Rules
FXI Service
Search
Route
Admin
Research Quadrant
View
Error Threshold Checks
Issuer Orphan
Escalate
Dispute Review
ClosePatch
Schedule
File Format Checks Generic File Outline Checks
Exchange Orphan Compliance RejectDemographic
Financials
CoverageCategory Processing
Case Structure By Entity WorkBasket Configuration Identify Fix & Process
Outbound File Generation Auto Add Auto Term Auto Close
Parsing Checks
Template – Adaptive Layers
Field Level Checks
RCNO Orphan
Spacing ChecksDesign Checks
SBM OrphanPPR Orphan
Pre-AuditRCNO PPR SBM
© 2017, COGNIZANT© 2017, COGNIZANT
T E C H N O L O G Y P I L L A R S
P E G A 7 + O R A C L E + E T L
Technology Transformation
Process
Business Rule
Data Flow
Batch
AU
TOM
ATIO
N
Adaptive Reconciliation
Framework
Electronic Health Record
Mobility
Cyber Security
Agility
DIG
ITA
L
Cosmic Calendar
Application Monitoring
Adaptive Recognition
Pattern Recognition
PredictiveAnalytics
MA
CH
INE
LEA
RN
ING
© 2017, COGNIZANT© 2017, COGNIZANT
Cosmic Calendar
Fully Configurable real time calendar to Schedule, Modify and Monitor Events without IT intervention
100% Real time
95% Automated
90% $ Saving
© 2017, COGNIZANT© 2017, COGNIZANT
Cosmic Calendar
- Access scheduled events all year around - Configure each enrollment event on the fly to assist
processing enrollments
- View details of an already configured Event and its holistic relations
- Update/Cancel configured enrollment events
- Singular View, A living & breathing calendar
- Shows all enrollment events scheduled by the business for tracking purposes
- Provides an ability to add events
© 2017, COGNIZANT© 2017, COGNIZANT
T E C H N O L O G Y P I L L A R S
P E G A 7 + O R A C L E + E T L
Technology Transformation
Process
Business Rule
Data Flow
Batch
AU
TOM
ATIO
N
Adaptive Reconciliation
Framework
Electronic Health Record
Mobility
Cyber Security
Agility
DIG
ITA
L
Cosmic Calendar
Application Monitoring
Adaptive Recognition
Pattern Recognition
PredictiveAnalytics
Event Gyration
MA
CH
INE
LEA
RN
ING
© 2017, COGNIZANT© 2017, COGNIZANT
Event Gyration
Establish proactive and reactive monitoring of key building blocks leveraging AES
100% Data Integrity
ZERO Down Time
Introduced Machine Learning
© 2017, COGNIZANT© 2017, COGNIZANT
Event Gyration
Proactive Monitoring
Dashboard
JMS Consumer
Email AlertsPe
gaAE
S
4
3
Alert Extension
CareFirst Common
Application LayerJMS Connector
JMS Listener
CDRIMD
CDW
BE
PICA
CG
Business Exceptions
Trigger JMS message to request for health check
Get component list configured for monitoring
Trigger JMS message back with health check results with configurable exception codes, message & email recipients
Call health check UTILITY for each component
1
2
Reactive Monitoring
Dashboard
JMS Consumer
Email AlertsPe
gaAE
S
Trigger JMS message with exception & addition information like Host Name, Node ID etc.
2
Post application exception by calling common utility.
1
Alert Extension
Application LayerJMS Connector
JMS Listener
CDRIMD
CDW
BE
PICA
CG
Business Exceptions CareFirst Common
© 2017, COGNIZANT
THANK YOU
© 2017, COGNIZANT
APPENDIX
© 2017, COGNIZANT© 2017, COGNIZANT
Event Gyration
© 2017, COGNIZANT© 2017, COGNIZANT
Staging Schema
File Format Check
File Header & Field Level Check
Error Threshold Check
Read and Send it to ERMSJMS
Queue
FileNetStore in FileNet
ERMS
Reconciliation Framework – File Intake
Pre Audit Preliminary Payment
RCNO Recon Output
Audit
Fed Exchange
© 2017, COGNIZANT© 2017, COGNIZANT
Enrollment and Reconciliation Management System (ERMS)
Business Rule
Compliance Reject
Issuer Orphan
Exchange Orphan
Reconciliation Framework – Business Rules
•Case
Workflow
Dashboard
PEGA JMS Listener
PEGA Rule Engine
First & Last Name
Gender
Demographic
Date Of Birth
Address
Total Premium
Member Premium
Financial
CSR
APTC
Facets
Rest / SOAP Web Services
© 2017, COGNIZANT© 2017, COGNIZANT
Enrollment and Reconciliation Management System (ERMS)
Workflow
Dashboard & Reports
Case Types
•Subscriber•Discrepancy•Enrollment•Payment•RCNO
Enrollment WB
Payment WB
Workbasket
Manager WB
…….
Update Facets
Dispute
Review
Escalate
Close
…..
Research Quad
Facets Auto Add &
Term
Off Cycle Auto Close
Reconciliation Framework – Workflow
PEGA JMS Listener
PEGA Rule Engine
Business Rule
Facets
Rest / SOAP Web Services
Actions
© 2017, COGNIZANT© 2017, COGNIZANT
Facets
PEGA JMS Listener
Enrollment and Reconciliation Management System (ERMS)
Enterprise Service Bus
Rest / SOAP Web Services
FXI Service
PEGA Rule Engine
•CaseFacets Add /Term
Dispute Report FormDispute Report FormDispute Report Form
Reconciliation Framework – Final Outcome
Business Rule Workflow
Dashboard