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I.T. Ensures Quick Compliance
November 1, 2007
Blue Cross Blue Shield of Massachusetts was up against an extremely tight deadline after the state legislature on April 12, 2006, mandated that by July 1, 2007, every resident must have health insurance. Payers, for their part, were required to offer coverage at a discounted rate to the upwards of 500,000 individuals eligible under the new program. And they had to begin doing so by May 1, 2007.
The Boston-based Blues plan wasn't completely caught off guard by the mandate; legislators had discussed the concept with payers in the state before the law was approved. But because many details of the legislation weren't determined until shortly before it passed, the Blues plan didn't have much time to plan for how it would comply, says Arthur Frontczak, program director for the health care reform.
After a quick evaluation, Blue Cross Blue Shield executives concluded that to meet the new law's requirements, a new application was needed to help customer service staff automatically generate and send quotes and coverage information to eligible individuals, enroll them and subsequently send new member data directly into the payer's proprietary managed care information system.
While the Blues plan does much of its own software development, executives determined they needed to work with a vendor to implement the new enrollment system in time to meet the compliance deadline. By December, the plan had a proof of concept for the new enrollment application from Pegasystems Inc., the Cambridge, Mass.-based vendor of the customer relationship management software the payer uses in its member services call centers.
Over the next four months, it worked with the vendor to jointly develop the BCBS Enroll application using the vendor's Payer Industry Framework application within its SmartBPM suite of business process management software.
"We considered a number of options, but because of the timeframe we had, we felt this was the one that would help us most quickly deliver a product," Frontczak says. "The framework is flexible so it allowed us to adapt quickly."
The Blues plan went live with the enrollment application on May 1. Within the first month of implementation, customer service representatives used it to generate 200,000 insurance quotes and enroll 1,500 new members.
It also included a proposed workflow for its BCBS Enroll application in the proof-of-concept agreement.
The plan and Pegasystems staff used the workflow and Web screen generation tools in the system to create the various screens and capabilities for the new application within four weeks. They also were able to show customer service representatives early versions of the application during that time, which helped the users become familiar with it before formal training began, Frontczak says. During the next seven weeks, the Blues plan trained the representatives and began testing the application to get ready for the May 1 go-live date.
The system enables customer service staff to capture and manage prospective member information from individuals via the telephone. It also enables them to automatically generate quotes or send quotes and other information via snail mail. In addition, the system can be used to enroll new members using information in paper or automated forms and submit them to the Blues plan's back-end systems via an 834 standard claims enrollment message.
Now that the Blues plan has met its deadline to implement a system to support the state's new insurance law, it plans to use the BPM software to develop a Web-based, front-end application to offer individuals another way to inquire about coverage. It also plans to work with the vendor to use the software to build a separate application to be used in its sales and enrollment departments. The application will help the Blues plan better track the status of contracts for coverage by establishing a single place to view and take action on them, says Ed Esposito, the payer's vice president of I.T. application delivery.
"The new system is going to incorporate different data and feed different systems than the one created for the health care reform project. But it's all associated with workflow needs," he says. "The BPM framework is our corporate workflow engine now, so we continue to look at other workflows that could benefit from this type of automation."
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