Washington Health Benefit Exchange

Transcription

1 Washington Health Benefit Exchange Financial Integrity and Risk Evaluation Clark Nuber

2 Why Perform Process Risk Evaluation? Within 3 years, HBE is forecasting $2B+ annually in premiums, 400,000 enrollees with over 4.5 million member months annually, and operating expenses exceeding $40M. Key business/financial risk factors may include: Inability to effectively manage all business processes Internal systems and procedures may not be working adequately Poor service leading to dissatisfied customers/stakeholders Over-reliance on one or few partners Overworked and dissatisfied employees. Loss in productivity 2

3 What Does a Risk Assessment Look Like? Process Flowcharting Risk Identification Narratives Risk and Control Matrix Heat-Map 3

4 Clark Nuber s Evolving Role Initially, the role was to assist management with performing an enterprise financial risk assessment, including: Flowcharting the processes Performing risk assessments Developing heat maps of risks Creating a risk control matrix of key controls and risks identified Role quickly evolved to become one of feet on the ground, and to assist management when it became apparent that certain processes were not established 4

5 Clark Nuber s Evolving Role (Cont.) Enterprise Risk Assessment role continues as processes are developed Clark Nuber s ultimate objective is to perform financial risk assessments, which does not include assurance on the Organization s internal controls, financial statements and/or compliance. 5

6 Areas Identified as High Risk 6

7 Lead Organizations Consumer Intake Vendor relationship, not Sub-Recipient Research of potential liability: Indemnification and Injunctive Relief written into Contractor Contracts, along with required Insurance standards for each Contractor, including Professional Liability Errors and Omissions, with a $25K deductible, and coverage of not less than $1M per occurrence/$4m general aggregate. Other required insurance, including Commercial General Liability, Umbrella Policy, etc. Ongoing Reporting and Monitoring Monthly reporting requirement for all contractors Ongoing monitoring of reports by HBE 7

8 Consumer Intake (Cont.) In-Person Assisters: Reducing risk of misconduct, by reviewing and follow-up with credentialing process Credentialing Process Required competencies Completion of required training Verification of language other than English (if any) Acknowledgement of a Conflict of Interest standard Acknowledgement of and In-Person Assister Code of Ethics Receipt of satisfactory background check 8

9 Consumer Payment Processing Payment Processing Complex process with multiple areas of risk and potential irregularities Incorrect Invoices and Rates: Quality assurance by HBE, Carriers and Blue Crane (ongoing QC) Lock Box 3 (Exception) Process Development: Scanning/Imaging Solution Assistance with Interdepartmental Handoffs Results of Work Management and timely resolution of payment exception processing Timely and accurate accounting and reconciliation of consumer payments Communication between departments 9

10 Payment Processing Flowchart (Summary) START HPF (Online): Credit Card or E- Check Recurring E-Pay K E Y Consumer KeyBank HealthPlanFinder Federal Govt. Carrier Cash Flow Info Flow Check Payment Key Bank LockBox 1 Key Bank Payment Verification Remittance File from KeyBank is Sent & Uploaded to HPF HealthPlanFinder Federal Government Exception Key Bank LockBox 2 KeyBank Manual Processing/Verification Deposit Report HPF Daily Trans. Report File Imported Automatically into Accounting System Key Bank LockBox 3 KeyBank Deposits Money Into KeyTreasury (Bank Account) HBE Manager Reviews and Authorizes Payment Sent to Ricoh via FedEx A Research and Reconcile HBE Accountant creates ACH File Identify Issue Scanned and Indexed Rejection/Consumer Communication by HBE Daily Cash Reconciliation 820 ACH KeyBank Payment Carrier FINISH Successful Deposit Data Available to Financial Call Center Consumer A Manual Adjust. 10

11 Payment Processing Flowchart (Detail) START Processing Risk Handled by KeyBank HPF (Online) Eligibility Recurring E-Pay NSF, Declined, Failed Transaction Notification from KeyBank Finance/Ticket to Ops Ops Research Consumer Communication Approved rates are loaded into E-Health Ratings Engine: E-Health Insurance (Third Party Vendor, holds all rates as approved by the OIC Monthly Invoice Call Center Check A Assist Rates Loaded Plan Selection Key Pay Payment Screen, E- Check or Credit Card Key Pay Confirmation Screen Enrollment Notification Incorrect Invoice Internal Pay Carrier Rates are verified and approved by HBE and Carrier. Blue Crane provides ongoing QC. A Check Payment Exception KeyBank Lockbox 1 KeyBank Lockbox 2 KeyBank Manual Processing/Verification KeyBank Payment Verification Remittance File from KeyBank is Sent & Uploaded to HPF HealthPlanFinder Daily.api File 834 Report (Daily): Enrollment Details to FEDS (tax credit information) FEDS FED Payment Deposit Report (Total Only) HPF Daily Transaction Report File Imported automatically into Sage, Records Cash and AP Segregate File Incorrect Payment Consumer Reject KeyBank Lockbox 3 File Rejection Entry into AP (Double Payment) Payment Issues Handled by Carrier KeyBank Deposits Money into Key Treasury (Bank Account) B Manual Entry of Data Sage User goes into AP and selects invoices ("Documents") to pay 820 Report (Daily & Monthly): Remittance Report Shows Payable to Carrier 999 Receipt & 820 with Customer Direct Payments Key Pay Console: Rejection and Transaction Reports, Lockbox Reports Finance Identify Issue Amounts Don't Match Research and Reconcile Sage user prints report of selected invoices with control total, Creates Entry Unauthorized or Incorrect Payment 834 Report (Daily & Monthly): Enrollment Details Inability to Identify Issue Daily Cash Reconciliation HBE Manager (TBD) Reviews and Authorizes Payment Carrier Ticket to Ops Policies on Lockbox 3 Issues File Sage User Enters payment Entry for invoices (cash and AP) Incomplete Payment Rejection Finance/Ticket to Ops Sage User creates ACH File and saves in "ACH Out" directory Rejection Threshold? Ops Research Reviewed and Approved by HBE Manager and Ops Manual Adjustment Hacker/Transmission Intercept Unauthorized Adjustment Incorrect Adjustment Amount Encryption of File, Sent to Key Bank via pdf Rejection/Consumer Communication Reviewed and Approved by HBE Amounts Entered Incorrectly Refund/Consumer Communication HBE Manager (TBD) reviews documentation and enters total into Key Pay from checks Selected B 820 ACH KeyBank Payment 11

12 Cash Disbursements Payments to Carriers (Consumer Premiums) Reconciling customer enrollment and remittance data is key to ensuring accuracy of payments to carriers Clark Nuber assisted with design of reports and reconciliation process to mitigate errors. Refunds and Adjustments to Consumers Certain manual adjustments will be necessary Clark Nuber assisted with development of communication process with Call Center: Health Plan Finder Results of Work Zen Desk Ticketing System Faneuil's CRM software Accurate and timely reporting and remittance to carriers Effective communication between Call Center and Finance Proper accounting and reconciliation of carrier payments 12

13 Cash Disbursements: Carriers 13

14 Recap and Moving Forward Process development has been a major area that continues to be addressed and fine-tuned as we work toward an overall financial risk assessment. Customer Intake Payment Processing Cash Disbursements to Carriers Others Clark Nuber s Enterprise Risk Assessment role will continue as these processes are firmly established. 14

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