Taking the Red Tape Out of Regulated Health Insurance - Pega · Pega Collaborative Healthcare Summit 2017 * Enrollment data as of August 31, 2017 . Customer Service Challenges •Multiple

Taking the Red Tape Out of Regulated Health Insurance Evolving Customer Experience with FUSE

Julie Feirtag | Associate Vice President, Customer Service - UCare

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UCare is an independent, nonprofit health plan providing health coverage and services to Minnesotans across the state.

Working in partnership with health care providers and community organizations, UCare currently serves over 370,000* members across government programs and the individual market

• Medicare-eligible individuals

• Individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance

• Adults with disabilities

• Individuals and families choosing health coverage through MNsure, Minnesota’s state insurance marketplace

• Our members are at the center of everything we do.

Health care that starts with you.

Pega Collaborative Healthcare Summit 2017

* Enrollment data as of August 31, 2017

Customer Service Challenges

• Multiple systems and complex navigation

• Product and compliance rules stored independently

• Many compliance and regulatory requirements

• Customer interactions are stored in yet another system (no real CRM)

• Customer Service work instructions and training built around how to find and interpret information

• Training and onboarding new employees takes too long

• Phone calls take too long

• Quality and coaching focused on navigation, compliance rules and scripts – not member experience!

You’ve all heard this story!!


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Product Line Member Considerations

Unique Onboarding Challenges

Medicare Concerned with annual changes in premiums, formulary and benefits

• Members request plan changes during open enrollment • Highly regulated down to the words we say • Requires collaboration across departments • Extremely tight time constraints

Medicaid and Disability Plans

May be enrolling and dis-enrolling frequently based on eligibility. Need for continuity of care.

• Dependent on state enrollment files and integration with enrollment department

• ID Cards mailed after enrollment complete • Members often need Customer Service assistance before we’ve

completed their onboarding

Exchange Plans Need to navigate both complexities of state exchange along with any plan they’ve selected

• Dependent on state exchange processes and procedures • Minimal visibility of member status during onboarding • Members want help, answers, support and service throughout the

onboarding process

Each Product Line Presents Unique Challenges


The Solution: Pega Healthcare for Customer Service


Fantastic UCare Service Experience

• All member service calls across all product lines

• 40+ unique intents and call flows (from view benefits, to review claims and everything in between)

• Streamlined from average of 14 systems/applications “open” down to 1 for many calls

• The FUSE application delivers on people, process and technology:

• A simplified agent desktop that reduces complexity agents face in handling and resolving customer questions and concerns

• Customer-centric processes that are designed to enable efficiencies and meet regulatory requirements

• Quality, integration and transparency across operations, I.T., and customer and product teams

A Vision for Service Transformation


Our Approach: Focus on the Outcomes


And get it done before open enrollment!

Oh, and…..Adapt to Change

• Respond quickly to changing regulations • Be ready for new products and new

membership • And everything else that changes along

the way

Pega BPM Allowed Us to Capture Requirements, Build and Demonstrate Along the Way


Regular “playbacks” to see the functionality as it was developed

We did not have data services during our construction – QA and Unit Testing were delayed until after the final iteration

A lot of discovery and remediation at final phase

FUSE was built in 11 iterations

+ 3-10

Iteration 11

It All Went Perfectly. So Easy.


https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwibxY-Kv_LVAhVB_mMKHaQzDO0QjRwIBw&url=https://pixabay.com/en/photos/rainbow/&psig=AFQjCNHdBXGDN2xXQM2alzNn7Fv3voAxNw&ust=1503754190087336

Challenge: Mitigated by:

Our business processes were not adequately defined or documented for this kind of project

• Involving business partners and stakeholders in DCOs and mapping sessions

• Documenting processes and business rules

We had to discover and build an integration layer for our data needs

• Regular and extensive playbacks • Creative problem solving • Decision making as we got close to “go live”

We built our FUSE processes with experts who knew how to navigate the current world

• Playbacks and UAT • A strong inclination to get it right • A healthy sense of humor

Challenges Caused Defects and Work-arounds


How’d We Do Overall?

Member Experience

Calls are more efficient and confident

Full transparency of issue through resolution

Usability and Efficiency

Reduced internal routing complexity

Reduced reliance on job aides and procedure documents

Reduced overall call handle time by <1:00 minute

Employee Onboarding and Engagement

Reduced new agent training/ramp up time by 50% with high quality/productivity

Love the Member 360 and intuitive call flows


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Product Line How’d we do

Medicare (Plan Changes)

• 100% accuracy with required scripts and disclosures • 100% internal accuracy on plan change requests sent to enrollment • Intuitive for CSRs (all relevant info in one place!) • Reduced average call handle time for plan changes by over 3 minutes!

Medicaid and Disability Plans

• Put to the test in May 2017 when 190,000 new Medicaid members added! • Staff trained and ready to support new members in record time (training time

<50% from prior years) • Member enrollment and ID card information available in Member 360

Exchange Plans • Added over 10,000 new members in 2017 enrollment • Billing and enrollment status visible to CSRs – supporting trouble shooting and

error resolution • Reduced average call handle time by 15 seconds

How Did Open Enrollment Go?


What would I do again? What would I change?

• Focus on the outcomes • Follow BPM • Co-locate the team • Business SMEs on development team • Implementation and change management

planning • Staged implementation

• Increase knowledgeable Pega resources • Increase knowledgeable call center/

operations resources • Start smaller • Conduct end-to-end process visualization • Approach to testing • Involve trainers earlier in development • Involve supervisors earlier in measurement

and process expectations

Lessons Learned


Additional Guiding Principles


“Out of the Box” does not mean “No Assembly Required”

• Know your processes and key measures

• Know your data and how things generally work

• Engage creative, design thinkers

Stay focused on delivering experience and outcomes

• Member needs and compliance rules that support

• Employee needs

• Business process needs and results

Acknowledge your obstacles and ADD VALUE ANYWAY!

Q & A

Documents

Taking the Red Tape Out of Regulated Health Insurance - Pega · Pega Collaborative Healthcare Summit 2017 * Enrollment data as of August 31, 2017 . Customer Service Challenges •Multiple