Pegasystems Inc. · NASDAQ:PEGA
Pegasystems — PegaWorld iNspire 2023
11 slides from Pegasystems's conference presentation, 2023
Slide 1: Improving Customer Satisfaction via CMS Star Ratings
Blue Cross Blue Shield of Michigan & EY US Improving Customer Satisfaction via CMS Star Ratings Amy Frenzel, Vice President, Service Operations Blue Cross Blue Shield of Michigan Monica McKinney, Director, Grievance and Appeals Blue Cross Blue Shield Michigan Tim Calhoun, Managing Director Ernst & Y
Slide 2: Introductions
Introductions Amy Frenzel Vice President of Service Operations Blue Cross Blue Shield of Michigan Monica McKinney Director of Grievance and Appeals, Blue Cross Blue Shield of Michigan Tim Calhoun Engagement Partner for BCBSM engagement Ernst & Young LLP (EY US) 2
Slide 3: Blue Cross Blue Shield of Michigan and BCBSM's Medicare Advantage
Blue Cross Blue Shield BCBSM’s Medicare of Michigan Advantage • Blue Cross Blue Shield of Michigan (BCBSM) is • Seventh largest Medicare Advantage (MA) plan in the US the oldest and largest health insurer in • Over 776k members in Group and Individual MA, Michigan and an independent licensee of the
Slide 4: Business problem & assessment and delivery approach
Business problem & assessment and delivery approach 4
Slide 5: Member and provider abrasion contributed to CMS Star Rating revenue loss
Member and provider abrasion contributed to CMS BCBSM – Senior Health Services Star Rating revenue loss Grievances & Appeals Core issues • A key metric of customer satisfaction is Operational inefficiencies defined by a health insurer’s Star Rating, as determined by the Centers for Medicare & Proces
Slide 6: Pega Grievances & Appeals Challenges
Pega Grievances & Appeals Challenges Pega Grievances & Appeals offering and methodology issues Topic Issues The Pega solution had degraded System health • Guardrail had degraded to 35 (95 is minimum) over a 3-year period and had Application design • Many scenarios caused “broken cases” the need to b
Slide 7: Assessment approach
Assessment approach Change Application management/ offering • EY US was engaged to conduct an operational training health and compliance assessment • Initial operational assessment identified an existing Grievances & Appeals Pega offering Application Methodology Assessment to be a core root cause of
Slide 8: Correction Plan & execution timeline
Correction Plan & execution timeline Delivery activities and timeline In collaboration, EY US and BCBSM defined a plan to correct course. • Guardrail correction and refactoring: the application technical and performance issues were resolved. Pega Design Review service engaged to confirm. • Offering
Slide 9: Outcomes and benefits
Outcomes and benefits 9
Slide 10: Outcomes and benefits
Tangible Pega Grievances & Appeals Outcomes and benefits offering outcomes The BCBSM Grievances & Appeals correction was successful and very well ü Operational process and functional improvements received by the business stakeholders resulting reducing the average number of days to complete a case b
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