AGS-430 the Digital Transformation Journey Mon Tesv3.Pptx

THE DIGITAL TRANSFORMATION JOURNEY OF CAREFIRST BLUE CROSS BLUE SHIELD

Harish Dwarkanhalli, VP & Global Delivery Head – BPM and Integration, Cognizant Jagdish Singla, Sr. Manager – Enrollment and Billing, CareFirst BCBS Alok Mandal, Principal Architect – BPM and Integration, Cognizant © 2017, COGNIZANT Founded in 1994 (CTSH, Nasdaq) 260,200 Employees (Dec 2016)

100+ Global Delivery Centers Headquarters: Teaneck, NJ

Revenue Mix Revenue NA: 78%, Europe: 16%, RoW: 6% $13.49B in 2016 (8.6% YoY)

Fortune’s Forbes Newsweek’s 2015 World Green Rankings Most Admired Companies Fast Tech 25 Years in a Row

Fortune Forbes Financial Times 500 Global 2000 Global 500

17+ years 100+ 13 Pega Partner Awards 10+ 2,600 long relationship with Pega Active Pega Customers Digital Industry Solutions Pega consultants Consecutive Awards 26,000+ Person yrs. 1500+ 2350+ Certified including Partner excellence 30+ Accelerators of Pega experience Successful Pega Projects consultants and Innovation 50+ Pega 7.x Upgrades 45 CLSA certifications 360⁰ Partnership Winner of 2017 Partner Excellence Award in Driving Customer Success: Winner of 2017 Partner Excellence Award In Driving Customer Success: Practice Breadth Practice Breadth & Depth & Depth © 2017, COGNIZANT Pega & Cognizant HealthCare Journey: Delivering Benefits Across Value Chain

Capacity to handle individual Productivity per CSR 500% application for large Blue 24% for large Payer Average Call Handling Time Onboarding Time for large 35% for large Payer 50% PBM player

FRONT OFFICE

Termination time for Physicians 66% for Global Healthcare giant Claims processing per hour 135% for a large Healthcare giant

Rework due to demographic data update 50% Number of Failed Claims 30% for a large Payer

MIDDLE BACK OFFICE OFFICE Claims Processing Cost for a Therapies for chronic patients 27% Health Insurance major 30% through Gaps-In-Care

TAT for Prior Auth for a Claims Payment Cycle for 28% large Payer 50% a Managed Care Org

The Changing Rules of the Game Implications for Payers Pega Driven Digital Transformation Imperatives Value Based Care Predicted to account for more than half of their business § Integrated healthcare ecosystem r within five years § Decision Hub § Intelligent Rule based Workflow Cognitive BPM Consumerism 68% Providers intend to engage § Predictive Analytics consumers to improve outcomes § Flexible Health Plan Configurators § Patient 360 Event Analytics

Population Health 80% Payers and Providers adding § OMNI-Channel Access Management capabilities within 12 months § Social Collaboration § Big Data Aggregation and Integration Digitization

§ Auto-adjudication through Robots 20% Follow up cost reduction § Workflow Optimization Operational Efficiency using remote health tracking tools § Care Mgmt. Dashboards Enhancement RPA § API & Microservices 60% Payers and Providers utilizing § Secured data exchange Shared Electronic Electronic Health Record (EHR) APIs Health Record (EHR) shared across organizations

MACHINE LEARNING AND AI AUTOMATION - DECISIONING - COGNITIVE BOTS - SELF HEALING

DIGITIZATION - MOBILE ENABLED SELF SERVICE - HANDLING SOCIAL FEEDS - TREND ANALYSIS FRAMEWORK - DESKTOP ROBOTIC PA AUTOMATION

PROCESS AUTOMATION

Optimized Business Process Automated Claims Process Intelligent Routing & Automation ~ 15 mins Time to Generate Quote Achieved 60% Efficiency Bringing in $750K of savings / year (reduced from 5 days)

Groups | Individual Markets Legacy Claims Processing Pega Deployment Tool | E-Comm Sales Quoting Claims Operations

Reduced Enrollment Fallouts by 75% Self-Service & Digitization enabling State through SLA Driven WorkFlow Automation Compliance (MHCC), CAQH integration and Direct Authorization Updates

Current Functional Spread 5+ Pega Adoptions Enrollments, Invoices, Payments, Delinquency and AE2, CDR, ERMS, PCC, 820 Collections, Escalation Management, Reporting, Frameworks utilized: HCIF, AES Reconciliation (PPR, Pre-Audit, RCNO, DRF forms), Renewals

Transaction Volumes Enrollments Total Active Enrollments – 800K 340K+ Invoices per month & Invoices Intake 20 or more reconciliation files per month Team and Technology Landscape A total of 1 million recon transactions Current team size: 50 Process payment receipts totalling $330M+ per month Pega’s PRPC, ETL, Oracle, TIBCO, Facets Total ID cards processed - 25K per month Facets

Servicing Reach Business Units 3 Jurisdictions : DC, MD, VA Small/Medium and Individual Markets Intake from On & Off Exchanges Sales and Marketing 4 different legal entities served: CFBC, CFMI, GHSMI, FirstCare Enrollment and Billing Dept Handle 8+ market vendors OTS (Operation Technical Support) Total brokers serviced: 5K+ Mandates, Internal controls

Missing Business Multiple File Manual Reconciliation Data Integrity Interface Formats and Follow-up Issues

• No visibility at batch processing • Multiple file types, validation • Huge volume of data across • Multiple checks/rule variations and its status with missing audit variants and duplicate various files for reconciliation dispersed across layers submissions caused data leakage • No ability to track and work • File aging while at discrepancies at enrollments, • Varied business rules based on validation process • Incorrect data at multiple invoicing, payments and jurisdictions, market segments outbound letters • Data was reviewed in excel renewals and legal entities sheets and corrections were • Missing auto-alerts when • Absence of real-time dashboard • Track and process made. Huge fines paid due to inconsistencies at data delta submissions non-compliance were found

Enrollment Reconciliation 2013 Automated Enrollment 2012 • Comparison of Subscriber enrollment • Intake file from Exchanges data with source system data • Pre-Enrollment Processing • Holistic view of the 834 enrollment • Primary Validations transactions • Group Assignment • Capabilities for users to rectify errors Healthcare Invoice 2017 Exchanges Production Support Payment Support • Generate Invoices TPM Portal 2012 Enrollment System Command Center 2016 Command Center 2016 • Automated triaging and monitoring of errors • Error Handling Capability • Validations on format of • Holistic view of payment file • Reduce manual dependency received files process starting from 820 file of billing / invoice related • Correction followed by intake to source system data and files processing Delinquency AE Command Center 2016 Command Center User Inputs • Validations on format of 2016 received files • Track all groups that have • Correction followed by their monthly payment in processing arrears Payment Reconciliation2014 Renewals 2015 • Posting subscriber payments to • Renewal Letter Generation enrollment system • Trigger benefit migration and track • Comparison of subscriber subsidy active & passive renewals payments with issuer system and • Special Enrollment Period related identify discrepancies Brokers functions • Resolve mismatches and tracking • Group Search, Contract Search and file search

Intelligent Processing Layers – Omnipresent I

Healthcare Automation • End to end business rule execution and validations Exchanges Layer • Data enrichment and compliance checks per HIPAA standards • Process automation and Outbound file processing/generation

Trends generation Reporting Adoption of digital device to enable configurations

User Inputs Digital Layers

Desktop automation Auto handle social at file validations media interactions Enrolment System

1. Generate fall out trends at 2. Decision trends to Construct 3. Align system assets based on Enrollment File Comparison / Generate Business rules predictions to process files

1. Capture intake volume 2. Predict volumes by Exchange, 3. Apply derived business rules Brokers Machine Learning patterns at Enrollments Jurisdictions and File types to auto fix discrepancies at files Layers Zero human Cognitive Bots !! intervention !! Artificial Intelligence • 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

TECHNOLOGY PILLARS

Electronic Application Process Health Monitoring Record

Business Adaptive Mobility Rule Recognition Adaptive Reconciliation Framework DIGITAL Pattern Data Flow Cyber Security Recognition AUTOMATION MACHINELEARNING Predictive Batch Agility Analytics

PEGA7 + ORACLE + ETL

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

Up to 85% Reuse

80% Increase

80% $ Saving

RCNO Pre-Audit PPR SBM

Template – Adaptive Layers Design Checks Spacing Checks Intake Processing Search Field Level Checks Error Threshold Checks Parsing Checks File Format Checks Generic File Outline Checks Route

PPR Orphan Admin

SBM Orphan Business Rules

RCNO Orphan Demographic Issuer Orphan Exchange Orphan Compliance Reject Category Processing Financials Coverage

Process Rules

Dispute Review Schedule Case Structure By Entity WorkBasket Configuration Identify Fix & Process Patch Close Escalate

Process Outcome Research Quadrant Outbound File Generation Auto Add Auto Term Auto Close View

FXI Service

Enrollment System (FACETS)

TECHNOLOGY PILLARS

Electronic Application Process Health Monitoring Record

Business Adaptive Mobility Rule Recognition Adaptive Reconciliation Cosmic Framework Calendar DIGITAL Pattern Data Flow Cyber Security Recognition AUTOMATION MACHINELEARNING Predictive Batch Agility Analytics

PEGA7 + ORACLE + ETL

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

100% Real time

95% Automated

90% $ Saving

- Singular View, A living & breathing calendar

- Shows all enrollment events scheduled by the business for tracking purposes

- Provides an ability to add events

- Access scheduled events all year around - View details of an already configured Event and its holistic - Configure each enrollment event on the fly to assist relations processing enrollments - Update/Cancel configured enrollment events

TECHNOLOGY PILLARS

Electronic Application Process Health Monitoring Record

Business Adaptive Mobility Rule Recognition Adaptive Reconciliation Cosmic Event Framework Calendar Gyration

DIGITAL Pattern Data Flow Cyber Security Recognition AUTOMATION MACHINELEARNING Predictive Batch Agility Analytics

PEGA7 + ORACLE + ETL

Establish proactive and reactive monitoring of key building blocks leveraging AES

100% Data Integrity

ZERO Down Time

Introduced Machine Learning

Proactive Monitoring Reactive Monitoring

Alert Extension Alert Extension

Trigger JMS message to 1 request for health check AES AES

Dashboa Email Dashboar Email rd Alerts d Alerts Pega Pega Business Business Exceptions CareFirst Common Exceptions CareFirst Common JMS Get component list 2 JMS Consumer configured for monitoring Consumer

Application Layer JMS JMS JMS JMS Application Layer 4 Trigger JMS message back with health Connector Listener 2 Trigger JMS message with exception & Connector Listener check results with configurable exception addition information like Host Name, codes, message & email recipients CDR Node ID etc. CDR IMD CG IMD CG BE BE CDW PICA 3 Call health check UTILITY for 1 Post application exception by CDW PICA each component calling common utility.

Fed Exchange

Preliminary RCNO Recon Pre Audit Audit Payment Output

File Format Check

File Header & Field Level Check ERMS FileNet Staging Schema Store in FileNet Error Threshold Check

JMS Read and Send it to ERMS Queue

Enrollment and Reconciliation Management System (ERMS)

Business Rule Workflow Facets Issuer Exchange Compliance Orphan Orphan Reject •Case PEGA Rule Engine

Demographic Financial Dashboard Rest / SOAP Web First & Last Name Total Premium Services

PEGA JMS Gender Member Premium Listener Date Of Birth CSR

Address APTC

Enrollment and Reconciliation Management System (ERMS)

Workflow

Facets Workbasket Actions Facets Case Types Auto Add & Business Rule Update Facets Enrollment WB Term •Subscriber Dispute •Discrepancy Payment WB •Enrollment Review •Payment Escalate Manager WB Off Cycle PEGA Rule •RCNO Close Auto Close Rest / SOAP Web Engine Services ……. …..

Dashboard & Reports

PEGA JMS Listener Research Quad

Enrollment and Reconciliation Management System (ERMS)

Facets

Business Rule Workflow

FXI Service •Case Facets Add /Term PEGA Rule Enterprise Rest / SOAP Engine Service Bus Web Services

Dashboard

Dispute Report Form PEGA JMS DisputeDispute Report Report Form Form Listener