DATA MANAGEMENT One Way to Improve ACA Collections PROPER CONTROLS AND ANALYTICS PROVIDE STRUCTURE AND INSIGHT he Affordable Care Act (ACA) has had a more profound effect on healthcare in America than any single piece of legislation since Medicare. Among the many sweeping changes it brought, it made an additional 30 million Americans eligible for health insurance. In all, the number of individual and Small Business Health Option Plan (SHOP) enrollees in the commercial health insurance market is estimated to grow from 12 million to approximately 60 million members. This growth represents an estimated $200-$300 billion market opportunity for commercial health insurers – if all parties pay. It All Starts With Good Data One of the early learning curves under the ACA relates to the decision to transmit consumer data electronically from the federal exchange via the same 834 files used by employers and third-party administrators. The data on the 834 files coming from the exchanges is more detailed and extensive and doesn’t quite map to existing systems built for group plans, forcing payors to make adjustments on the fly. More importantly, it can be extremely difficult, time consuming, and costly for payors to confirm eligibility and to process enrollment in a timely and accurate fashion because of the way the data is reconciled. Members who do not pay their premiums within 90 days of signing up are not even true members. Reconciliation delays create stress and aggravation among enrollees in the plan. The importance of eligibility and enrollment reconciliation cannot be overstated; it is the gateway to turning reform into revenue. Essentially, nothing else can occur in the database until: • Enrollment data has been validated • Members’ eligibility for a particular level of plan is confirmed • Any government subsidy and cost sharing reduction (CSR) amounts have been factored • The first premium payment is received and processed A New Era of Controls There are a great many variables to contend with under the ACA, exacerbated by the exponential increase in member data that must be maintained, driven both by new enrollees and the volume of health records on file for existing members. Yet while the ACA creates a number of unique challenges to insurance payors, it also provides a unique opportunity to dramatically increase their customer base. Doing so relies on precise data controls and eliminating errors from the slate. Automated controls ensure data integrity with a system of checks and balances by examining each transaction and bit of data on an 834. The controls compare the 834 to all T 14 HBMA BILLING • MARCH.APRIL.2015 By Sumit Nijhawan
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