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Anthem Government Business Division• Who we Are

– In 2012, Amerigroup merged with Wellpoint which subsequently was renamed Anthem

– The Anthem Government Business Division (GBD) serves members across the country through affiliated Medicaid, Medicare, CareMore and Federal Government Solutions businesses

– GBD services 8.1M members through products for low-income families and people with disabilities and government sponsored healthcare programs

• Our History with Pega– Customer Service (2010)– Claims Repair (2011)– Pharmacy Prior-Authorization (2012)– Appeals (2012)

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2010 Launched

Auto-Adjudication (AA) optimization program

2011

Goa

l 3 percentage points improvement in Auto-Adjudication (AA) rates

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Claims Processing Optimization: First Step

2015 Status: 9 Percentage Points AA Improvement

2011

Tech

nica

l Sol

utio

n Deployed Pega Claims Repair

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Step Two: Claims Intake Optimization, 2011• Situation: Large membership growth due to geographic

expansion, acquisitions, and legislative changes expected to significantly inflate claims volumes

• Response: Front End Re-engineering initiative

• Claims Load Problem: Current process did not have capacity for anticipated claims volume

• Short Term Solution: Streamline front end editing using Pega

• Long Term Solution: New design, including Pega, and improved scalability by utilizing multiple instances

• Initial Result: 67% reduction in claims load processing time with introduction of first business rule in Pega

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#PegaHC

Pega Claims Deployment Timeline

Dec 2010 Pega Claims Repair

Kick off

Oct 2011 Pega Claims Repair Initial Go Live

June 2012 Pega Claims Intake Initial

Go Live

Nov 2013 Pega Front End

Workstation Go Live

Dec 2014 Pega Claims

Workstation Go Live

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A Modular Claims Solution

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Claims Adjudication Engine

Pega Interface Extension

Facets Integrated Claims Repair

Claims Intake Claims RepairClaims Data RepositoryFront End Audit Review

Claims Workstation

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Step Three: Claims Workstation• In 2013, a small Pega Claims Workstation was developed as a tool for repair of paper claims

• With the success of this installation, we moved onto the larger Claims Processing population, to create the Medicaid Claims Workstation

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CLAIMS WORKSTATION CHARTERImprove financial and payment accuracy for easy to complex claims

Improve our efficiency (claims per hour) by bringing multiple decision points, steps, and resources into a single, architected & decision-enabled interface

Provide a single, intelligent interface for analysts to use to process claims, eliminating the need for toggles to other applications and enabling faster decision-making on aspects of the claim

Enable consistency of process across markets & regions of processing like claims types, while still allowing for customization based on market-specific requirements

Allow for easier, more consistent training programs across the Medicaid claims organization

Provide real-time knowledge to the analysts for the claim being worked

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Phase Details & IT Resources• Pilot Business Rule

– Detailed process maps were created to capture the rules to resolve pended pilot claims.

– These maps helped identify opportunities to integrate the claims work station tool into the claims processes.

– The maps also served as a foundation for developing user stories to perform agile development of the tool.

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Phase 0Q1-Q2 2014

• Validate Facets + PegaInterface

• Process mapping

Phase 1aQ1-Q2 2014

• Process mapping• Visionary Mock up Build• Visionary Requirements

Phase 1bQ2-Q3 2014

• Build of Requirements

Phase 2 Q4 2014

• Build out the ability to execute the business rule process in Claims Workstation

RESOURCESPEGA ANTHEM1 LSA (6 mos) 1 BA1 LBA (2 mos) 4 Developers

IT TIMELINE Requirements: 2 months Development: 4.5 monthsTesting: 1 month

Go Live: 12/17/2014

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Claims Workstation: High Level Process

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• Pega pulls pended claims from Facets using web services & stored procedure calls to get required claim & supporting data

• These claims go into a workbasket in Pega to be worked manually by claims analysts

• Screens & business rules were designed in Pega to walk the claims analyst through the process necessary to resolve the claim

• Once the changes to the claim are made, Pega updates Facets with the appropriate information

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Challenges• Business Rule Selection

• Determination of best business rule to choose based on impacts to the claim on adjudication

• Facets Integration• Interim process created until web services

release from vendor• Process is a combination of real-time updates

and nightly batch adjudication• Web service solution will be entirely real-time

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Claims Workstation Results• Claims priced & finalized through Workstation: 23,338

• Related claims Finalized/Adjusted by the system(not touched by a processor): 3,269

• Estimated capacity created since go live: 3.9 FTEs

• Quality: 100% accuracy found by random audits

• Pilot first month results – 3,592 claims finalized by 3 analysts; 1,197 average

per processor

• Pre-Pega base-line measurements November, 2014– 3,208 claims finalized by 8 analysts, 401 average per processor

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~3x boost in productivity

Feedback from our MCR partners has been positive. Tool is easy to use

and a “very forward moving

process”.

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What’s Next?• Upgrade to Pega 7• Integrate with new web

service• Continue Business Rule

Creation• Migrate Legacy Queue

Management tool to Pega

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Q & A