Friday, April 25, 2014

Case Management and Business Process Management – Benefits to Healthcare Payers

Executive Summary:

Impact is one of the eagerly awaited events of the year, the main reason being the slew of products and new features that are introduced by IBM. The application of new products and features to solve real world problems, demonstrated by solutions implemented at some of the prominent fortune 500 firms, makes every penny spent attending the event worth its value. The big product offering I am looking forward to in this year’s event is the Case Management features embedded with Business Process Manager (BPM) capabilities, thus making the processes truly smarter. Application of flexible, intelligent Case Management capabilities combined with the visibility, control and integration capabilities that BPM provides would be interesting to watch. This is even more valuable in the current setting of the Healthcare sector.

Need for Case Management in Healthcare:

With all the changes happening in the Healthcare payer sector in lieu of regulations and increasingly tough insurance market, now is the need more than ever to have flexible, smarter processes. The need of the hour is to continuously monitor market trends, identify insurance products that are not cost efficient, refine the market strategy, create flexible customized products and introduce the products within the shortest possible time to market. The best employees of Healthcare payers, with years of invaluable domain knowledge behind them, are better off applying their best judgment and making prudent decisions during the critical business processes than spend time in a swivel chair (duplicating data entry in multiple systems).

Case Management, with its feature to provide the user with the ability to review documents and choose a workflow depending on the case, can be a valuable asset.  For example, a claim review specialist reviewing a request for claim authorization, is better off reviewing the applicable benefits, claim pricing at one place in a single system with all required document images, rather than logging into different benefit systems and pricing systems, searching for the applicable benefits and pricings and performing the authorization review. After the review, the claim review specialist could choose to kick off a medical code review workflow or a payment approval workflow depending on the case. This flexibility, combined with the process visibility and legacy system integration capabilities offered by BPM could end up as a blessing. Robust document management capabilities provided by Case Management helps provide the user with the complete picture and reduces any time needed to develop a customized solution.

Case Management, BPM, Decision Management and Advanced Data Analytical capabilities combined could even lead to new business models, products and services for the Healthcare payers.

Smart people in organizations deserve to work with smarter processes and this new offering promises to provide that.

All in all, it sure is an exciting time to be in Vegas.

Next week, Prolifics will be a Platinum sponsor at IBM Impact 2014, where our team will be showcasing our BPM solutions and recent successes. If you are planning to attend IBM Impact, be sure to visit Prolifics at booth #401 or schedule a one-on-one meeting with one of our experts.

To learn more about Prolifics’ BPM solutions, visit or connect with N.R. Vijay.

N.R. Vijay is a Solution Architect in the Business Process Management division of Prolifics. He has over 10 years of consulting experience across domains such as Retail, Healthcare and Banking. Specializing in technology, management concepts and enterprise strategy, he is focused on change management and process improvement initiatives. He co-authored a whitepaper titled "Improving Customer Loyalty through Business Process Optimization and Advanced Business Analytics"