THE DIGITAL TRANSFORMATION JOURNEY OF CAREFIRST BLUE … · THE DIGITAL TRANSFORMATION JOURNEY OF CAREFIRST ... Winner of 2017 Partner Excellence Award In Driving Customer ... Reconciliation

© 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


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


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


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


§ 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


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


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


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


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


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


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


Adaptive Reconciliation Framework

Established ‘Adaptive Reconciliation Framework’ for quicker adoption to new changes

Up to 85% Reuse

80% Increase

80% $ Saving


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





Process

Business Rule

Data Flow

Batch

AU

TOM

ATIO

N


Framework


Mobility

Cyber Security

Agility

DIG

ITA

L

Cosmic Calendar



Pattern Recognition

PredictiveAnalytics

MA

CH

INE

LEA

RN

ING


Cosmic Calendar

Fully Configurable real time calendar to Schedule, Modify and Monitor Events without IT intervention

100% Real time

95% Automated

90% $ Saving


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





Process

Business Rule

Data Flow

Batch

AU

TOM

ATIO

N


Framework


Mobility

Cyber Security

Agility

DIG

ITA

L

Cosmic Calendar



Pattern Recognition

PredictiveAnalytics

Event Gyration

MA

CH

INE

LEA

RN

ING


Event Gyration

Establish proactive and reactive monitoring of key building blocks leveraging AES

100% Data Integrity

ZERO Down Time

Introduced Machine Learning


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


Event Gyration


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


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



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


Actions


Facets

PEGA JMS Listener


Enterprise Service Bus


FXI Service

PEGA Rule Engine

•CaseFacets Add /Term

Dispute Report FormDispute Report FormDispute Report Form

Reconciliation Framework – Final Outcome

Business Rule Workflow

Dashboard

Documents

THE DIGITAL TRANSFORMATION JOURNEY OF CAREFIRST BLUE … · THE DIGITAL TRANSFORMATION JOURNEY OF CAREFIRST ... Winner of 2017 Partner Excellence Award In Driving Customer ... Reconciliation