Case Study: Healthfirst achieves rapid digital onboarding and operational agility with Pegasystems

Healthfirst rapidly onboards membership amidst COVID-19 disruption

Healthfirst, the largest nonprofit health insurer in New York, was modernizing its core operations when COVID-19 hit and membership surged 15%, including more than 250,000 new enrollments. Its legacy enrollment and administration systems were built for rigid, first-time processing, making it difficult to keep up with rapid eligibility changes, regulatory updates, and increased demand across enrollment, claims, and provider management.

Pegasystems helped Healthfirst modernize these functions with the Pega Platform™, including intelligent automation and the HIPAA 834 model to route and automate enrollment work. As a result, Healthfirst seamlessly enrolled over 250,000 members, processed 98% of enrollment transactions automatically, kept enrollment costs flat, reduced provider onboarding time by 77%, automated 75% of provider data updates, raised claims first-pass rate to 92%, and auto-processed 40% of prior authorizations.

Healthfirst

C.J. Brexel

Vice President of Application Development