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The Marketplace has been rapidly growing. Plans struggling to keep up may soon be left behind.

Carrier exits, expansions in subsidies, and Medicaid redetermination are driving spikes in Affordable Care Act (ACA) enrollments. Plans able to capitalize on these sudden enrollment surges can gain a dedicated membership overnight; however, manual processes can limit growth.

Bright Health’s exit, left an industry gap of over one million individuals. End-to-end automation helped Softheon-partnered health plans to enroll most ex-Bright Health members.

With the rapid growth in the ACA Marketplace, one clog in the enrollment journey can leave plans falling behind.

Health plans both new and well versed in the government markets know about the headaches of executing billing and payments.

But now, times are changing.

Advancing ACA technology offers automated solutions to once manual processes. One Texas health plan simultaneously reduced manual overhead while improving the member experience.

Angry Members, Missing Subsidies, and Stretched Resources: The dangers of inaccurate payment processing

Inaccurate and late invoices, reconciliation delays, and a lack of oversight into payment transactions can result in lost revenue.

Issues caused by billing and payment challenges include:

  • Inaccurate enrollment data resulting in member abrasion
  • Delayed or missed subsidy payments leading to a decline in membership rates
  • Payment data inconsistencies resulting in excess labor and noticing
  • Damaged relationships with regulators

All of these issues contribute to a lack of membership growth. Scaling can be difficult when internal resources are used to solve day-to-day member issues.

Learn more about the challenges and how one health plan overcame them with Softheon’s off-the-shelf (OTS) billing & payment solution.

Health plan sees 16% growth in net PMPM income with billing & payments solution

To stay competitive in the ACA, health plans need to grow.

A Texas plan identified that its manual payments process was preventing them from scaling its membership.

Softheon’s billing & payment platform enabled the health plan to increase effectuation rates. Through an improved membership experience and automated reconciliation and noticing processes, the plan saw significant membership growth – 228% over the 7-year period.

Net ACA enrollments only increased by ~29% during the same period. This health plan was able to exceed industry standards by using its increased payment processing capabilities to target underinsured demographics.

A consistent increase in membership resulted in the net income on a PMPM basis growing by 16%, after Softheon fees were considered.

Billing & payment automation allows plan to break into new markets

Softheon’s platform enabled the health plan to offer innovative programs and better serve underinsured demographics.

One of these programs now accounts for nearly 25% of the total membership count. A population that would be completely ineligible without the capability to support third-party payment programs.

Download our premium billing & payments use case to learn how the health plan used innovative premium collection to break into new markets.