Pega Foundation for Healthcare Enhancements Help Payers and Providers Accelerate Access to Care

Updated on March 11, 2023

Pegasystems Inc. (NASDAQ: PEGA), the low-code platform provider empowering the world’s leading enterprises to Build for Change®, today announced enhancements to Pega Foundation for Healthcare enabling healthcare organizations to accelerate access to care at scale for their customers.  With expanded interoperability, intelligent AI-powered decisioning, and personalized responsive benefits, the solution helps streamline the myriad of processes and regulations that frustrate payers, providers, and customers.

The growing complexity in the healthcare system continues to outpace advances in digital technology intended to simplify it. For example, the Centers for Medicare & Medicaid Services recently outlined hundreds ofnew procedural changes required to transition from the COVID-19 public health emergency that will impact an estimated 16 million individuals. These ongoing changes will make it difficult for health insurance providers to continue to authorize payments in a timely manner, for healthcare providers to manage their patients’ care, and – most importantly – for consumers to get the care they need.

By applying AI and automation to critical bottlenecks in the healthcare system, Pega helps care organizations keep pace with healthcare system changes to help ensure patients receive the care they need. This allows them to rapidly deploy targeted operational processes and streamline back-end processes while increasing personalized engagement at a lower cost. Available today in Pega Foundation for Healthcare, the new features provide the following benefits to care organizations to help deliver better customer health outcomes:

Speeding customer assistance with intelligent routing: Operations and service teams are overwhelmed with customer requests and struggle to meet service-level agreements. With out-of-the-box workflow automation capabilities, Pega enables payers and providers to intelligently triage these requests and either automatically resolve them or route them to the most appropriate available person who can address it in a timely manner. This helps organizations not only speed resolution but also save valuable resources.

Cultivating more customer trust with real-time care updates: Digitally savvy customers expect the same real-time transparency into the status of their care journey in the same way they use apps to track online shopping orders from the warehouse to their door. Using advanced Pega Digital Experience APIs, Pega enables care organizations to easily connect backend workflow systems to outbound channels that keep customers informed of their care status in real time. This empowers the customer to know exactly where they stand in the process – for example, if they have been approved for continuity of care or a prior authorization for a specific treatment option – while allowing providers and payers to deliver complete transparency on the customer’s status, which engenders more trust.

Providing more dynamic care options with responsive benefits: Providers need to offer better digital experiences to support treatment compliance, which can be critical to driving positive health outcomes. New features in Pega can help support treatment compliance by dynamically detecting and removing barriers in customers’ care journeys. For example, the system can detect when patients aren’t taking their medications and then launch a rewards program to encourage better compliance, or a patient that has exhausted a certain plan benefit can be provided an automatic exception in certain situations.

Pega Foundation for Healthcare, Pega’s flagship healthcare solution, streamlines healthcare enterprise workflows while accelerating care outcomes for payers and providers. Leveraging RESTful APIs, including HL7 FHIR® clinical resources and models, the solution connects the healthcare enterprise together, enabling clients to derive insights and take action on the overwhelming volume of healthcare data. This enables payers and providers to speed access to care, support care innovation, and manage compliance – from provider directories to transparency to prior authorization processing.  

Pega works with the largest healthcare organizations to meet their compliance, operational, and strategic objectives as they transform their digital experiences. Its solutions are used by all of the top 10 US healthcare payers along with many leading health system providers. Pega software enables organizations to personalize customer interactions with empathy in their moment of need and in their preferred communication channels. It also connects data and systems across operational silos to streamline organizational complexity while improving efficiency, business agility, and the customer, provider, and employee experience. For more information, visit

Quotes & Commentary

“Healthcare organizations’ resources are stretched beyond capacity as they try to keep pace with high customer expectations while navigating increasing complexity,” said Susan Taylor, vice president and industry market lead, healthcare and life sciences, Pega. “By applying AI and automation to critical decision points in an organization, Pega Foundation for Healthcare enables payers and providers to speed service and engage with customers on a more personal level, all while lowering costs and saving employees time and effort.”

About Pegasystems

Pega provides a powerful low-code platform that empowers the world’s leading enterprises to Build for Change®. Clients use our AI-powered decisioning and workflow automation to solve their most pressing business challenges – from personalizing engagement to automating service to streamlining operations. Since 1983, we’ve built our scalable and flexible architecture to help enterprises meet today’s customer demands while continuously transforming for tomorrow. For more information on Pegasystems (NASDAQ: PEGA), visit

The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.