Client
One of the Largest Independent Pharmacy Benefit Managers (PBM) in the US
In the complex landscape of US healthcare, our client serves an impressive 20 million members. Committed to enhancing healthcare accessibility, they have a comprehensive suite of services, including cost-saving programs, prescription benefits, Medicare Part D plans, and mail-order and specialty pharmacies tailored for both individuals and groups. Their mission is to ensure that every member receives the medications they need while navigating the complexities of healthcare with ease and efficiency.
Challenge
Breaking Free from Legacy Constraints
Our client faced significant operational challenges that impacted their mission to deliver timely and effective services:
- Eligibility and Claim Files Processing: The old system took over 24 hours due to outdated manual procedures. This delay not only affected customer satisfaction but also posed risks to operational efficiency and compliance.
- Manual Onboarding Process: The manual interventions and onboarding processes for member demographics and new plans were complex and time-consuming. Extensive data entry and verification processes for each new member caused delays in service initiation.
- Outdated Legacy Systems: The client ran their operations on two separate legacy PBM platforms. These created silos of information, hindering seamless communication between systems. This system fragmentation led to inconsistent data and a lack of a unified view of member information.
- Fragmented User Experience: The lack of integrated platforms resulted in a disjointed user experience for clients, members, and brokers. Users experienced static interfaces (non-intuitive), making it difficult for them to navigate services and access information.
- Data Complexity: The duplication of information across multiple instances and the lack of a unified view of Members, Claims and Eligibility make it challenging to manage data effectively and hindering accurate analysis.
Solution
Architecting a Next-Generation PBM Platform
With a focus on enhancing member experience, automating processes, and modernizing the technical architecture, Hexaware partnered with the client to implement a comprehensive transformation strategy. Here’s what we did:
- Enhanced Member Experience: We implemented comprehensive end-to-end modernization and rebranding efforts, focusing on creating an intuitive UI/UX across all digital properties, including the Member Portal, Eligibility Portal, and Administrative Portal. This transformation led to significant improvements in user engagement and satisfaction.
- Eligibility and Accumulator Files Automation: Our solution enabled near real-time loading of client eligibility files, facilitating efficient accumulator data exchanges and claims processing. This automation ensured timely and accurate data management.
- Rebate Aggregator Migration: We updated current systems and integrations to streamline the rebate management process. This adjustment addressed the challenges posed by the frequent changes in the rebate aggregator, ensuring a seamless experience.
- Comprehensive Modernization: We successfully delivered a scalable, member-centric eligibility platform designed to overcome the limitations of legacy systems. This modernization effort enhances operational efficiency and supports future growth.
- Agile Transformation: By adopting distributed Agile practices, we significantly improved engineering efficiency and productivity. Streamlining development and testing through automation and the implementation of DevSecOps principles improved time to market for rolling out new features and functionality.
Benefits
Enhancing Claims Processing and Member Experience with Intelligent Automation and Modern Architecture
By modernizing the PBM systems, the client achieved significant benefits for their business, their members, and stakeholders:
Operational Excellence
- 40% Faster Claims Processing: The implementation of intelligent healthcare automation solutions improved first-pass resolution rates, enhancing overall operational efficiency.
- 30% Fewer Defects: We reduced the number of defects in the system through modern engineering practices and rigorous testing, ensuring a more reliable service.
- 25% Productivity Improvement: The adoption of Agile methodologies and automation training significantly increased team productivity, enabling faster service delivery.
Business Impact
- Future-ready Platform: We delivered a high-performance, secure, scalable, and future-ready eligibility system through implementing microservices-based architecture.
- Cost Optimization: By modernizing the PBM systems, we reduced operational expenses, allowing the client to allocate resources more effectively.
- Reduced Technical Debt: By eliminating legacy systems and processes, the client achieved significant savings and improved their ability to innovate.
Enhanced Member Engagement
- Benefits Transparency: Enhanced member engagement through the portal by creating dynamic and seamless experiences across multiple channels.
Summary
Setting New Standards in PBM Services
Hexaware partnered with the client to transform their eligibility management processes, overcoming inefficiencies, modernizing legacy systems, and enhancing member engagement. The result is a secure, compliant, and future-ready platform that delivers a seamless experience for all stakeholders. This case study highlights how strategic digital transformation in healthcare can improve healthcare access and member satisfaction, eventually contributing to better health outcomes for millions.
