Meryl S t e wa r t, B CBS MN. Leon S a b a r s k y, B CBS NC K e i t h Dayt o n, Pega. April 16, 2014

Transcription

1 Featured S peaker: Meryl S t e wa r t, B CBS MN Facilitator s : Leon S a b a r s k y, B CBS NC K e i t h Dayt o n, Pega April 16, 2014

2 Agenda Welcome Housekeeping Join us at PegaWORLD! Plan Spotlight Blue Cross Blue Shield of Minnesota Wrap Up 2

3 2500+ Colleagues from the Pega Community 220+ World s Leading Companies Learn the Latest in Pega Technology with Training Sessions & Workshops 50+ Customer Success Presentations Exciting Customer Keynotes to be announced Unlimited Networking Opportunities Register Today! Special discounted rate of $695. Register now through May 2 nd using code PW14BLU695. This offer may not be combined with any other discounts. 3 Register at: using code: PW14BLU695

4 Let s Talk PEGAWORLD 2014 Look Who s Attending PegaWORLD 2014 LET S TALK PegaWORLD 4 Aetna Alere Amerigroup Assurant BCBS Alabama BCBS Michigan BCBS Minnesota BCBS North Carolina BCBS Tennessee Bristol-Myers Squibb Cambia Health Solutions Carefirst BCBS 38 Leading Healthcare Organizations 7 sending 10 or more people Cigna CVS/Caremark Fallon Community Health Plan Florida Blue GE Healthcare Group Health Cooperative Health Alliance Plan of MI Health & Human Services Health Net HealthNow Highmark BCBS Kaiser Permanente Medical Mutual of Ohio NASCO OptumHealth OptumRx Prime Therapeutics QTC Management Quest Diagnostics SBPASC Telerx TMG Health Ucare United Concordia UnitedHealth Group WellPoint

5 Healthcare Agenda Main Stage Panel, 6 Breakouts, Special Interest Group, PegaFORUM Lunch Session Utilization Management Panel with Cambia (Regence) Retail Sales Panel with Fallon Community Health Plan and Carefirst BCBS Customer Service/ Appeals & Grievances Panel with Optum and Wellpoint (Amerigroup) Provider Contracting with UnitedHealthcare Claims Exception Automation with SBPASC (Carefirst) Smart Claims Engine with Cigna Healthcare Special Interest Group on Sunday, 6/8 Main Stage Transformation Panel featuring CIO from UnitedHealth Care PegaFORUM Lunch for BCBS Organizations on Monday, 6/9 5

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7 Harnessing Change at BCBS MN 7

8 BLUE CROSS AND BLUE SHIELD OF MINNESOTA BCBS MN is the largest health plan in Minnesota providing coverage to nearly 2.8 million members. BCBS MN generates over $8 billion in annual revenue and processes more than 38 million claims per year. Purpose: We make a healthy difference in people's lives." Products and Services: BCBS MN provides health plans & related products for employers & individuals; life insurance; long-term care plans; pharmacy benefits management; administrative services for self-insured groups; financial spending accounts & health & wellness programs. 8

9 MARKET DRIVERS AND COMPETITIVE TRENDS 1 Heightened Competitive Landscape Increased local competition from national partnerships. 2 Challenge to Grow and Retain New organizations are entering health plan market. 3 Increasing Government Role Government mandating transactions and clinical interoperability standards (e.g. PHR). Regulatory and compliance mandates. Accounts are demanding different products and services for their employees. Customer loyalty depends on delivery of data, wellness & employee engagement. Consumer cost-sharing requires timely, useful information to support informed decision-making. 9 New government product opportunities.

10 REQUIREMENTS FOR CHANGE True business ownership and enablement. Business to own their processes. Business to own their rules. Business enabled for rapid change. IT focused on business strategic initiatives. 10

11 THE JOURNEY BEGINS Searching for software to power the Technology Framework. Provide capabilities to deliver more agile business solutions. Improve time to market. Enable business process design and rule management. Enable business rule sharing across operational solutions. Enable the management of end-to-end transactional processes. Provide a toolbox approach for reuse of developed components re-use what you build. Enable new strategic business initiatives while leveraging investment in core transaction systems. 2006: Selected Pegasystems Business Process Management software. 11

12 BUSINESS PROCESS MANAGEMENT A software system which allows for the direct execution of business processes. Removes the costly and time intensive development of process-specific software. Allows the full business process to be defined. Can invoke external services to perform business operations. Can send messages to human workers requesting they perform certain tasks. Can call a Business Rules Engine to make automated decisions. Provides a process driven user interface. 12

13 BUSINESS RULES Business rules are abstractions of the policies and practices of a business organization. They create an unambiguous statement of: What a business does; Decision making policies. The formal specification becomes information which is used in running the process and rules engine. 13

14 PEGA IMPLEMENTATIONS FIRST DEPLOYMENTS Pharmacy Transaction Manager National Provider Identifier Exception Management Medicare Crossover Adjustments Exception Management Post Adjudication CCM / Split, Wait and Hold** Enrollment Framework Multiple Products Key: Claims Initiative ** Claims + Finance Initiative Enrollment Initiative Health Management Initiative Incentive Based Benefits Pharmacy Drug Enrollment Member Reconciliation MSHO Integrated Health Management 14

15 PEGA IMPLEMENTATIONS LAST FIVE YEARS 4010 Pre- Adjudication Electronic Provider Adjustments Automated Adjustments NPI / MCA / CVS Exception Management 5010 Pre- Adjudication Lump Claims Medicare Membership Exception Management Pre- Adjudication Dashboard Exchange State Mandate Ancillary Processing ICD 10 Pre- Adjudication Key: Claims Initiative Enrollment Initiative Small Group Renewal 15

16 TRANSACTION BASED ARCHITECTURE 16

17 Claims Agility in Practice at BCBS MN 17

18 ICD10 INITIATIVE: OVERVIEW Process claims as per ICD10 compliance mandate. Enhance Pre-Adjudication solution to correctly process claims containing ICD10 diagnosis and surgical procedure codes. Continue to support current ICD9 code version until needed. Build solution to be extensible for future ICD code versions implementation. Agility Development Effort 1 Developer: 50 hours for framework. 1 Process Architect: 10 hours. 18

19 ICD10 INITIATIVE: APPROACH & BENEFITS Technical Approach Implement configuration to set the ICD10 Mandate date. Implement configuration to manage the ICD Code version that is being used for processing. Deliver code that is flexible and reusable. 19 Benefits Framework is in place to support future enhancements. Process Architect from the Business manages any future changes without IT involvement. Manage any mandate delay for 10/1/2014.

20 ICD10 INITIATIVE: TEST EXECUTION BENEFITS Manage future date testing. LISA tool is utilized to perform future date testing. No need to maintain multiple sets of Test cases, reused for all testing. Test Team able to alter the ICD Code version setting based on scenarios. Test Team able to alter the ICD Mandate date based on scenarios. Deliver quality test execution. Shorter test plan creation cycle. 20

21 NASCO MIGRATION: OVERVIEW Reduce disruption of migration to new core adjudication system. Implement NASCO with a phased approach by migrating groups in iterations. Release claims in a controlled manner at the start of each iteration. Agility Development Effort. 1 Developer: 1 hour for framework process flow, decision table, and UI for releasing single or bulk claims. 1 Process Architect: 1 hour orientation meeting. Using solution as needed. 21

22 NASCO MIGRATION: APPROACH & BENEFITS Technical Approach Implement the concept of HOLD functionality. Benefits Issues are easily identified and recovery effort is minimal. Greater flexibility/ability to support changes in migration rollout. Business agility without IT involvement. 22

23 Empowering the Business to Handle Change 23

24 BUSINESS AGILITY ENABLEMENT SUCCESS FACTORS Process Architect 24

25 BUSINESS-CONTROLLED: ICD CODE CHANGES Providing Business Agility - Dynamic updates 25

26 BUSINESS-CONTROLLED: ITS STATE MANDATES ITS state mandate delivery supported by cross functional teams in challenging environment. Multiple environments / multiple projects. ICD10 development in Test and Integration (ICD10). ICD9 Testing in Integration and Quality (ITS). One code base for Pre-Adjudication. Test Managers collaborated and utilized the soft switching of the ICD code settings when needed. 100% testing compliance achieved. Minimal IT involvement; related to infrastructure stability and support. 26

27 BUSINESS-CONTROLLED: NASCO MIGRATION Process Architect is able to code HOLD criteria. Change is applied, tested and refined in the QA environment. Hold releases can be executed either by selecting a single claim or releasing in Bulk. Claims still able for Portal Correction, just not delivered outbound. Examples of HOLD criteria: Hold all NASCO MEDIX. Hold only certain COBA ID s for first pass validation. Hold all NASCO Paper Claims. 27

28 BUSINESS CONTROLLED: PROCESSING AUTOMATION Best practice from COE to provide a stub for Auto correction and Business rulesets. Business constantly evaluating production patterns/rejects and determining opportunities for process improvement. Primary NPI Process Process Claim Determine Routing Set Default NPI Auto Correct AUTO CORRECT EXAMPLES Reworking Minneapolis to MPLS, Saint Paul to ST PAUL for exact matches on NPI correction. Mapping Claims containing Multiple NPIs to a specific Legacy ID. Choosing Legacy ID s based on Bill Types. 28

29 Increasing Business Control at BCBS MN 29

30 CONTINUED FOCUS ON BUSINESS CONTROL GOAL: Increase number and impact of business controlled functions. Expand from decision rules, to process flows, framework design, report development and workflow design. FACTORS: Opportunity identification / fit; software maturity, strategic prioritization & support; resources Project Candidates 30

31 Build for Change Pega software revolutionizes how leading organizations optimize the customer experience and automate operations. 31