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
Our Speakers for Today
Lisa Ledford-Crissey, Vice President
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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
Care Management Operational Solutions, Anthem
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
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 Anthem’s Care
Management Solutions (ACMS)
Anthem - A Brief Overview
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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
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
Our Focus at ACMS
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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
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
Anthem Team Made it Happen
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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
All About Pega CRM @ Anthem
Pega’s Unified Platform Empowers Anthem’s View
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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
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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
Implementation Methodology & IT Challenges
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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
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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
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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
User Journey Until Now
Testimonials From Our Users
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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
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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.”
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.”
What Lies Ahead: The Future Roadmap
What Lies Ahead: The Future Road Map
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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
Discussion and Conclusion
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