Case Study: OptumRx cuts turnaround from days to minutes and eliminates fraud, waste and abuse with Pegasystems' Healthcare Industry Foundation on Pega Cloud

OptumRx Safeguards Health and Eliminates Waste

OptumRx, one of the largest pharmacy benefit managers in the U.S., faced a Centers for Medicare and Medicaid Services mandate to eliminate fraud, waste and abuse and better safeguard member health, forcing a rapid reevaluation of its IT systems and processes.

OptumRx implemented Pega’s Healthcare Industry Foundation on Pega Cloud to build a suspicious case‑handling system for pharmaceutical claims across Commercial and Medicare Part D, going live in under four months. The solution cut turnaround times dramatically (from days to minutes), improved auditability, reduced manual touchpoints and boosted scalability, efficiency and accuracy.

OptumRx

Steve Graese

Director of Strategic Systems