'Smart' BPM application helps reduce expensive claims exceptions handling; provides powerful new functionality for integrated, front-to-back-office healthcare suite

 Pegasystems Inc. (NASDAQ: PEGA), a leading provider of smart, rules-based business process management (BPM) software, today extended its suite of industry-specific BPM applications for the healthcare industry. Continuing to execute on its promise to deliver an integrated front-to-back-office solution set, the company announced PegaHEALTH Claims Repair Version 4, designed to help healthcare payer organisations reduce operational costs by increasing first-pass claims resolution and helping to eliminate claims backlogs.

PegaHEALTH Claims Repair is the newest application in a broad suite of healthcare solutions from Pegasystems. In addition to packaged, best-practice applications to support and optimise claims processing, the company provides solutions that increase productivity and the quality of customer interactions across the enterprise, including both member and provider services. The company’s software is installed in healthcare payer organisations covering nearly 35 million individuals, including over one-fifth of the nation’s Blue Cross Blue Shield organisations. Pegasystems works with industry-leading companies, including CSC and IBM, to deliver these solutions to the healthcare market.

“Manual claims processing costs healthcare companies on the order of $3.2 billion each year, according to industry estimates,” said Tom Congoran, vice president, Healthcare, for Pegasystems. “Every percentage point a company can shave from expenses is that much more in potential profit. PegaHEALTH Claims Repair has been designed to do precisely that – deliver an enterprise-wide impact from a nimble platform that changes quickly to accommodate market shifts.”

For today’s healthcare payer, ongoing industry change has made claims processing an expensive, complex, and resource-intensive process. The demands of emerging consumer-driven health plans, changing federal and state mandates, and increasingly complex risk-sharing agreements between payers and providers, have all combined to push traditional claims adjudication systems to their limits. PegaHEALTH Claims Repair helps maximise the value of existing payer systems, infusing them with greater intelligence by utilising rules-based, ‘smart’ BPM to help ensure that claims adjudication occurs automatically, consistently and cost-effectively. By providing greater control over the claims process, PegaHEALTH Claims Repair enables payers to create innovative benefit designs that can help expand their product offerings and increase competitive advantage.

Automating the claims process from pre-adjudication through claims finalisation, PegaHEALTH Claims Repair applies best-practice business rules to help check, correct and translate common claims edits, such as member eligibility, timely filing or duplicate claims. The application also enables the acceptance of the “837” claims format, to assist with Health Insurance Portability and Accountability Act (HIPAA) standards compliance.

Typically, back-end healthcare payer IT infrastructures are a combination of legacy systems – membership, medical management, claims, etc. – each with its own data format, making importing data into claims processing systems both inefficient and expensive. As a result, most payers manually process 30 to 50 percent of all claims submitted. Through one-click integration forms, PegaHEALTH Claims Repair can easily integrate with core processing systems or other applications, without duplicating functionality, to extract the required data needed for claims resolution.

“With the inherent intelligence of IT systems, there’s no reason for the level of manual claims processing that healthcare companies accept today,” explained Pegasystems’ Tom Congoran. “PegaHEALTH Claims Repair harnesses that intelligence at the right level – outside the hard-coded processes – to help companies handle most of their claims automatically and put the savings back on their bottom lines.”

Blue Cross & Blue Shield of Rhode Island (BC&BSRI) executives will present a compelling profile of Pegasystems’ healthcare solutions in action when they speak at leading industry forums this week and next. Attendees at Gartner’s CRM Summit in Baltimore, March 15-17, and at the BCBSA Customer Contact Center Conference in Atlanta, March 21-24, will hear in detail about how BC&BSRI deployed its Pegasystems contact center solution in five short months, for less than $5 million.    

Platforms, availability, pricing
PegaHEALTH Claims Repair is available immediately through Pegasystems and its partners. It runs on Windows, AIX and Solaris platforms, and the IBM DB2 and Oracle databases. Contact Pegasystems or an authorised partner for pricing information.

About Pegasystems
Pegasystems Inc. (NASDAQ: PEGA) provides rules-based, smart business process management (BPM) software to large organisations, helping to deliver significant ROI and providing them with the flexibility and agility to respond to changing business needs. With annualised revenues of approximately $100 million and a blue-chip customer base, the company offers applications for the financial services, healthcare, insurance and government markets, as well as a cross-industry BPM application. Pegasystems is headquartered in Cambridge, Mass., and has regional offices in North America, Europe and the Pacific Rim. For more information, visit www.pega.com.

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For information, contact:
Jeremy Payne           
Pegasystems Europe
+44 118 965 1641
jeremy.payne@pega.com

Alex Crawshaw
Pirate Communications
+44 (0)20 7760 7050
alex@piratecomms.com


Forward-Looking Statements
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