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Pegasystems Drives New Efficiencies in Health Care Coordination

May 24, 2012 No Comments

SOURCE: Pegasystems

Amerigroup Deploys Pega for Better Claims Performance and Service Excellence

CAMBRIDGE, MA–(Marketwire – May 22, 2012) – Pegasystems Inc. (NASDAQ: PEGA), the leader in Business Process Management (BPM) and software for customer centricity, today announced that Amerigroup Corporation has significantly increased its claims first-pass rate within just three months of deploying Pega Claims Repair, and is on track for even higher efficiencies in the near future. This success follows several other operational and service enhancements achieved by Amerigroup through deployment of Pega’s healthcare solutions.

Amerigroup, a Fortune 500 company, coordinates health care services for more than 2 million individuals across 12 states in publicly funded healthcare programs such as Medicaid, Medicare and Children’s Health Insurance Program (CHIP). The Virginia Beach, Virginia-based organization is dedicated to improving access to care and increasing the quality of life for its members while proactively working to reduce the overall cost of care to taxpayers.

Pega’s Claims Repair solution has improved adjudication and overall operational performance with powerful and intelligent automation eliminating manual effort and improving coordination of benefits at Amerigroup. Deployed initially for duplicate claims, Pega technology has driven nearly a three percent increase in Amerigroup’s claims first-pass rate. Amerigroup is now applying Pega for auto-authorization processing where similar gains are expected.

Amerigroup’s use of Pega technology started nearly two years ago when it deployed Pega Customer Process Manager for Healthcare (CPM-HC), a process-driven, multi-channel CRM solution tailored for healthcare organizations. In deploying CPM-HC for authorizations and customer service, Amerigroup has provided new levels of service excellence noticed by providers and members alike, and produced tangible efficiency improvements including a 50-percent reduction in new hire training time, and significant reductions in work for departments such as claims.

Pegasystems counts renowned providers, government agencies, and top life sciences companies as healthcare clients. Pega is used by three of the largest pharmacy benefit managers (PBMs), 13 out of the 15 largest health payers, and more than 65% of the Blues network. PBM clients handle more than 55% of the nation’s prescription volume; payer clients write more than 50% of all direct premiums.

Quotes & Commentary:

Russell Esposito, Senior Vice President of Information Technology Services at Amerigroup
“Pega has become a critically important technology within our software portfolio. Pega’s software provides new capacities for delivering agile sets of solutions that meet or exceed customer expectations. We are able to implement business process improvements across the enterprise, and reduce operating costs while simultaneously improving customer satisfaction, as well as care for our members. It’s impressive and gratifying to watch the kinds of complex advancements achievable in a relatively short timeframe.”

Janice Young, Program Director, Payer IT Strategies, IDC Health Insights
“Externalized rules-based, BPM solutions provide health plans with tools to improve processing efficiency and flexibility, while continuing to leverage legacy investments. These strategies present win-win scenarios for health plans by preserving existing investments and establishing the efficiency and flexibility needed to succeed in the current market and also position for the emerging market value based and quality based collaborative programs.”

Keith Dayton, Senior Director, Healthcare, for Pegasystems
“Healthcare Payers today are enormously constrained by their core administration systems. They are claims-centric when they should be customer-centric. Pega is bringing customer-centricity to healthcare. Our newest solutions are moving the process and logic out of the claims system to the control of the business units themselves which enhances our enterprise-wide value to organizations like Amerigroup. We applaud Amerigroup’s accomplishments in serving some of the most vulnerable populations.”

Supporting Resources

To see a video on how Amerigroup is leveraging Pega technology, visit:

To read more about other Pega customers’ successes, visit:

To read more about Pega’s wide range of healthcare solutions, visit:

To learn more on how world-class organizations are leveraging Pega technology for customer service at PegaWORLD 2012 on June 3-5 in Dallas, visit

RSS Feeds for Pegasystems Press Releases, Pegasystems Media Coverage and Pegasystems Events

About Pegasystems
Pegasystems, the leader in business process management and software for customer centricity, helps organizations enhance customer loyalty, generate new business, and improve productivity. Our patented Build for Change® technology speeds the delivery of critical business solutions by directly capturing business objectives and eliminating manual programming. Pegasystems flexible on-premise and cloud-based solutions enable clients to quickly adapt to changing business conditions in order to outperform the competition. For more information, please visit us at

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