10 Vital Questions to Ask When Negotiating for a Health Insurance Marketplace Solution from Technology Integration & Implementation Vendors

Transcription

1 10 Vital Questions to Ask When Negotiating for a Health Insurance Marketplace Solution from Technology Integration & Implementation Vendors Is there an existing ACA compliant Healthcare System for Public & Private Marketplaces that is currently operational and cost effective? An Industry Report By Mason Grigsby & Jim Minihan mason@imergeconsult.com jim@imergeconsult.com

2 Preface Faced with the ACA challenges, some of the common questions asked by Health Insurance Company C-level executives include; We need a high performance ACA Health Care Solution that can operate error free and has the ability to connect seamlessly to any Health Care entity Federal, State, Consumer, Payer, Broker, or Navigator. I want the system to be available now for a reasonable cost. Not $134 million, not $78 million, it means $1million or less. It must be a complete solution for Launching, Connecting and Operating within all Insurance Marketplaces Consumers, Brokers, Exchanges, and Navigators. The system should offer Eligibility and Enrollment, Plan Management, Premium Billing and Account Management. It must have a customer facing self - service portal for Exchange/Marketplace access, Member and Government Billing, Claims Pricing and Processing, Easy Correction and Updates, automated control over Processes, Network/Website Performance, and Manual Processing Reconciliation with Exception Reporting and data analytics including revenue projections from Federal subsidies. So, What Are the Major Healthcare Insurance Market Challenges That Must Be Overcome? The market is littered with failed systems owed to poor architectures and lack of understanding of the business operational issues. A proper system should require no in-house staff to manage software or hardware and the cost should consist of a single up-front implementation fee ($1M or less) with only an ongoing member transaction fee, based on the membership count. Page 2 of 12

3 The Key Issues in an Error Free ACA Marketplace Platform 1. Upfront Implementation and Ongoing Cost; 2. Time to Implement; 3. Seamless Data Interchange with Federal and State Based Marketplaces; 4. Elastic Scalability to Meet Business Demand; 5. Data Verification & Reconciliation; 6. Connectivity to an Insurer s Dispersed Disparate Systems; 7. Effective Invoicing, Payment Processing, Reconciliation, and Exception Handling; 8. Timely Member Effectuation with Insurer s Admin Systems and CMS; 9. Accurate Edge Server implementation for Risk Adjustment and Re-Insurance; and 10. Monitoring and reporting of key performance indicators. The features of an integrated system should include: Streamlined Implementation without the need to replace or modify current IT systems Connectivity to all Health Care Exchanges and government entities. Automatic updating to databases without keying of data from a paper form to reduce labor costs Member Verification and Data Correction capabilities, including reconciliation and exceptions, claims management, delinquencies, partial payments, refunds, bad debt and reporting. The system provides a low cost payment portal for credit card and ACH transactions. Premium Billing, Payments, and Adjustments, error and omission controls, two party billing, member & government billing and correction capability with payment reconciliation and Broker commission calculations & payment. Page 3 of 12

4 A customer facing self-service portal with automated eligibility, enrollment and disenrollment transactions for individuals, families and small groups, brokers and navigators. An Identity Management module that insures authentication of members to reduce fraud, and support desk calls. for re-issuance of passwords Fully functional Customer Service Capability for fast response to Member enrollment and billing issues including duplicate bills or corrections, appeals/grievances; enabling increased cash flow and reduced Call Center labor cost. Business Process Management and Workflow that seamlessly interacts with all system processes thus insuring completed transactions with all parties and to provide performance metrics. Data Mining/Analytics capability to evaluate all aspects of the business including market penetration down to a zip code level and cost of operations. Mobile Support that offers access to the Exchanges and Customer Service Centers by the consumer, employer, broker, partner and navigator, includes a payment option (credit, debit card/ach transaction) as well as a Lockbox for paper check transactions. The Softheon Report Desk turns operational data into useful information to analyze trends such as claims tracking, market penetration by zip code, and ad hoc reports on any operational activity. Reports can be created for any desired timeframe in real time. So, what are the key challenges to acquiring a fully functional ACA Health Care Solution? Page 4 of 12

5 #1 Is the System Operational, Proven and Cost Effective? There is a one-time up-front fee (less than $1mm) and an on-going per member transaction fee. The costly implementation fees for custom installed systems in the ACA Marketplace are eliminated providing a low cost, risk free implementation. The solution can typically be deployed in less than 90 days and has a proven track record as highly scalable and elastic to meet demand. Built in features include intuitive screens for all users, connections to Federal & State Marketplaces, Business Process Management/Workflow with preconfigured Affordable Care Act rules with high levels of security & fraud detection. An industry standard web portal that includes direct enrollment, off-exchange enrollment, a payment gateway, as well as account management for individuals, brokers and employers. The user screen is a Portal to Exchanges and other entities: State, Federal, Private, Providers, Brokers, Hospitals and Insurers. Seamless connectivity is built into the system. #2 Is there Flexible Eligibility & Enrollment Management? Unified enrollment and underwriting for all sales channels including Federal, State and single/multi carrier private exchanges along with Advanced Payment Tax Credit (APTC) determination using integration with the Federal Data Hub & and an Electronic Data Interchange (EDI) gateway enrollment, as well as ACA compliant billing and payment. Availability of plan shopping for Individuals, Employers, Brokers and Employees using a direct enrollment / off-exchange portal including; Plan Selection and Comparison, including the filtering of various plan components, Premium quotes that do not require a completed application process to start shopping for plans and benefits, Enroll customers through the Health Plan portal, including; Strong authentication and identity management, and Direct Enrollment coupled with Centers for Medicare & Medicaid Services (CMS). Ability to enroll policies through Off Exchange plans. Page 5 of 12

6 Capability to search and store provider information for both on and off exchange enrollments. Processing of eligibility information to the Federal Data Hub. Provide automated tools that validate and cleanse enrollment data before it is imported into core administration systems. Rate Verification Validated exchange-provided rates with real-time updates. Zip Code/FIPS Code/Rating Area Validate zip code, county and rating area to identify invalid enrollments, duplicate SSN. Identifies enrollments received where Exchange ID or Social Security Number combination already exists. #3 Does it have Complete Financial Management & Premium Billing Capability with Electronic Bill Presentment, Payment, Corrections, Chargeback Adjustments and Archiving? A central Financial Management module, that provides direct individual and small group billing Electronic Bill Presentment, Member & Government Billing, adjustments, nonsufficient funds and chargeback processing. An integrated Lockbox for paper billing and archiving of invoices for Customer Service access. Ability to make payments through the consumer portal, including processing payments through several payment channels (echeck/ach, Credit and Debit Cards, etc.) and apply payments in real-time towards customer accounts. Business Process Management (BPM) that verifies accounts and payment amounts, updates accounts, links data and documents and updates the Member Account via EDI processes. Ready for integration with the Federal Edge Servers for risk pool subsidies data exchange. Page 6 of 12

7 #4 Is Plan Catalog Management Easy to Implement with; Valid Health Plan Benefit & Rate Data, Real-Time Rating, Legal Compliance; ACA Qualified Health Plan Certification, Compliance Monitoring, Risk Adjustment and Reinsurance? Plan Catalog Management; a single source for all health plan benefit and rate data, real-time rating engine for Marketplaces, ACA Plan certification, recertification and compliance monitoring of Qualified Health Plans (QHP) with risk adjustment and reinsurance. An intuitive, easy to use connection for creating, editing and exporting a Health Plan issuer s entire product offering to reduce redundancy and errors, as well as streamlining the Summary of Benefits & Coverage (SBC) processes. System for Electronic Rate & Form Filing (SERFF) and Health Insurance Oversight System (HIOS). #5 Is there a Customer Relationship Management Function that provides all of the Healthcare Delivery and Supply Chain Elements for Subscribers, Brokers, Navigators and Exchanges? Provides customers a view of their financial status, invoices and notices through a member portal; Provides the ability to serve customers through both public and private exchanges including; Process address change requests Add/Remove Dependents Request ID Cards View Benefits and SBCs for current plans View account statements and notices Make payments Business Process Management/Workflow modules to capture all content associated with a member for immediate distribution to Customer Service and Subscriber functions. Page 7 of 12

8 Tools to scan documents and capture legacy data from any source to index as well as seamlessly link to Subscribers, Exchange Marketplaces and other 3rd parties. Bill history/content repository offers real-time compliance, appeals & grievance data for queries from any source with security access. #6 Is there a Security Hierarchy for all Account Data? Compliance with all Federal Privacy laws and regulations. Firewall security between layers for HIPPA mandate encryption (in transit & in cloud server). The Marketplace infrastructure needs t o b e further protected by segregated layers of security mechanisms such as network address translation, managed security between transactions & trusted, account access with step up authentication. Full redundancy to insure continuous operations. #7 Is there a Small Business Component to the System? The Small Business Health Options Program (SHOP) component of Marketplace platforms can assist small group employers by providing access to a variety of QHPs. Key functions of SHOP supported by Marketplace platform include: Verification of employers and employee & determination of eligibility through the Federal Data Hub, Ability of employers to search, compare and select QHPs, Calculation, collection & payment tracking of employee contributions, Health Information system fee processing & Navigator payments, and Management & tracking of employer and employee payments to the QHP s. #8 What is necessary production performance? The system has been proven by its use by a major healthcare payer with : Over 200,000,000 electronic cases and documents on-line 20 terabyte document repository for searching, comparing and selecting qualified health plan products, Page 8 of 12

9 Over 1,000 concurrent users with guaranteed uptime performance, and Over 100,000 new documents captured and archived daily. #9 Does your solution include the Hardware and Software Edge Server Capabilities that incorporate Risk Adjustment, Risk Corridor and Re-insurance Calculations? Manage automation of inbound 837 EDI Claims Transaction files from the Client s core claims administrative to be imported into CMS Edge Server. Ability to handle various file naming formats from disparate sources (i.e. Pharmacy, Medical, Dental claims), including variations on file extensions. Link Claims transactions (837) to members and secure claims to authorized users of the application Establish strict business rule requirements to meet the provisions defined in ACA for reinsurance and risk adjustment payment calculations. Business rules include; Enrollment Span Validates claim was processed and approved during the time that the member had health insurance coverage Duplicate Claim Prevent processing of duplicate claims Enrollment to Claims Reconciliation Ensure that data within claims records can be fully reconciled against enrollment #10 Are there any Cloud Based ACA Platforms in Production Operating Successfully? Many Health Insurers use cloud based platforms for ACA integration and implementation. In 2014, 22 health plans have selected Softheon MC2 for Federal and State Marketplaces, including Coordinated Care Health, Buckeye Community Health Plan, NovaSys Health, Sunshine State Health Plan, Magnolia Health, MHS, Total Health Care, Florida Healthcare Plans, First Care, Community Care of Oklahoma, Care Oregon, ATRIO, Community First Health Plans, and more. Gesinger Health, Delta Dental, and Coventry have selected hcentive webinsure as the cloud based marketplace platform. Page 9 of 12

10 Vendor Evaluation In 2014, a growing number of healthcare payers are reporting outsourcing or considering outsourcing for member and provider transactions (enrollment, claims, customer service, etc.). In addition, although most health plans will focus much of their current energy on Web delivery; the marketplace interface must be an integrated, multichannel initiative, which will be required indefinitely. The ACA compliant Public and Private Marketplace implementation is not a specific technology or application, but it is a corporate strategy that must support activities such as: Product design, QHP certification assessment, comparison and selection Administrative transactions (for example, eligibility, enrollment, premium billing, payment processing, and demographic updates) Financial transactions (for example, Non-Sufficient Fund NSF, partial payment, etc. which may trigger ACA Delinquency and Termination transactions) Decision modeling and reporting tools Vendor product evolution s h o u l d b e focused on integration, data standards and transaction management, rather than presentation. Vendors that focus on above strategies and healthcare payers that adopt vendor solutions that support data integration and interfaces between applications and the presentation layer will be in the best position to support Public and Private Exchange strategies. The ACA compliant vendor landscape includes new comers such as hcentive, Benaissance, and NFP Health, as well as mainstream vendors such as BenefitFocus, Connecture, ikasystem, DST Solutions and Trizetto. However, Softheon Marketplace Connector Cloud (MC2) is the most innovative marketplace platform with the most ACA installed base. Softheon Softheon MC2 is a Software as a Service (SaaS) cloud solution that is ready to plug into your environment. This means you avoid the capital costs of server hardware and software along with the operational cost of maintaining staff to operate it. The MC2 Cloud server is backed by over 14 years of experience in Health Insurance Process Management with 40 systems across the U.S. A cloud solution offers a unique opportunity to limit risk and contain costs with a proven plugin system. Softheon MC2 ACA Cloud Solution Organizations are searching for packaged software, such as Softheon MC2, to provide a full, operationally proven solution. They want to speed u p the customer service process, cement the relationships between the organization and the consumer, as well as sell additional products to their existing customer base. MC2 provides seamless access to information by dynamically linking any computer, document image, , check image or text document in a virtual, electronic file folder, making that file available anywhere, anytime. Page 10 of 12

11 Figure 1. Softheon Marketplace Dashboard Softheon MC2 is tightly integrated with all major credit card processing centers with full PCI and SSAE-16 certifications which allows clients to accept credit and debit card transactions without having a merchant account. Page 11 of 12

12 Conclusion Today s ACA systems operate with incomplete information -- islands of technology exist that do not communicate with each other. Information is electronically unavailable, unreliable, error prone or inaccessible in another digital repository. This translates to significant errors in enrollment, billing mistakes, increased telephone and labor costs due to subscriber callbacks. It also means fewer revenue generating opportunities due to a lack of accurate marketplace data and the analytical tools needed to evaluate your business.. Healthcare payers will spend considerable time and money on interim piece-meal applications that support disjointed ACA marketplace interfaces. Softheon MC2 is an integrated cloud-based platform. Marketplace members, employers, and brokers will be provided with increasing information, but that information will be fragmented and incomplete. Softheon MC2 Member, Employer, and Broker web portals are unified and access the same source of truth repositories. There is no data latency or inaccuracy due to data replication. Multi-channel integration across Public and Private Exchanges will continue to be a challenge for Health Insurers. Industrywide, member information required to support defined contribution will not be fully or easily supported. Softheon MC2 includes health insurers using the platform for ACA Federal and State Based Marketplaces. Few vendors focus on product designs that are consumer driven. The nation s first fully operational state exchange has been using Softheon MC2 since 2008, serving over 200,000 consumers. Softheon MC2 is designed for marketplaces as a result of collaboration between government and health plans. Initial revenues will come from ACA consumer acquisitions and shift consumer behavior based on new data resources that help consumers make better choices. Softheon MC2 supports health plan s marketplace strategies, generating new revenue opportunities but also managing the risk through partnership and integration capabilities. Media Inquires To learn more about Softheon and Our Cloud-based Exchange Solutions, contact Yvonne Villante: pr@softheon.com or Ext 1 Page 12 of 12