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Health plans face significant challenges managing monthly Affordable Care Act (ACA) enrollment reconciliation

Outdated systems, a lack of interoperability, and everchanging policy regulations result in additional hurdles health plans must overcome.  Common issues caused by reconciliation challenges include: 

  • Inaccurate enrollment data resulting in member abrasion 
  • Delayed or missed subsidy payments. 
  • Mismatches between upstream and downstream systems causing data inconsistencies. 
  • Poor results on CMS Alignment Scorecards  

Automate the process through end-to-end workflows 

Business rule configurations performed independently of backend core programming can streamline the reconciliation process by creating complete end-to-end process workflows. These workflows are designed to be customizable and adaptable to respond rapidly to the changing needs of health plans.  Reconciliation with CMS may seem daunting, especially for health plans looking to join the  Marketplace during this oncoming boom in ACA enrollments. Experiencing a large volume of enrollment discrepancies with CMS can result in rejected claims, lost revenue, and a deteriorating member-experience.   The minimum reconciliation data files a health plan must process includes: 

  • Pre-Audit Files  Provided by CMS and displays the currently enrollment state of all individuals. 
  • Reconciliation Inbound (RCNI) Files  Required to be submitted by health plans monthly, detailing the state of enrollments in their system through a complex algorithm. 
  • Reconciliation Outbound (RCNO) Files  Provided by CMS in response to the RCNI and flags discrepancies found between CMS and the health plan’s enrollment data. 

Both human-error and administrative overhead can be eliminated by automating the processing of these files and, in turn, the entire reconciliation process. 

Invest in seamless communication through an integrated system 

The proper configuration of a technology platform to align enrollment and financial data will ensure success. Keeping all sources in sync and communicating well provides stability between CMS and health plans of any size.  The monthly enrollment reconciliation requires robust communication between independent systems, particularly CMS. Results of monthly reconciliation are shared through scorecards provided by CMS directly to the health plans.   An isolated solution that fails to communicate effectively with other systems can: 

  • Result in a single point of failure. 
  • Delay the alignment of enrollment and financial data 
  • Fail to meet CMS regulations. 
  • Compromise both inbound and outbound files. 

Integrating with downstream core admin systems enables accurate, bi-directional data transfer and reconciliation between issuers and exchanges. 

Increase enrollment data accuracy with additional reconciliations 

Health plans are turning towards the concept of composability when building their technology ecosystems. Composable, modular solutions require a high degree of interoperability as these issue-specific solutions must effortlessly communicate with each other to execute effective end-to-end processes, including reconciliation with various sources.  A successful health plan functioning on the ACA Marketplace must take additional precautions when ensuring the accuracy of their enrollment data. Daily and automated reconciliation processes with payment vendors, health plan’s payment solutions, and enrollment data can prove advantages without needing to invest additional resources. Ensuring proper integration and communication with third-party and internal sources enables daily reconciliation to occur automatically.  

Position yourself in a way that allows you to rapidly adjust to regulation changes 

A one-size-fits-all solution is no longer realistic as more vendors switch to a corporative collection of business capabilities designed to work together and address specific business needs. Modular solutions can be utilized to provide custom solutions to satisfy specific requirements and improve the overall userexperience  Rapidly responding to reconciliation regulation changes proves key to the longevity of a health plan in the ACA.  Monthly enrollment reconciliation experiences the greater number of changing policies and regulations compared to the other components of enrollment in the Marketplace. With the revitalization of the ACA that recent legislation caused, additional policy changes are to be expected as CMS adapts to meet a growing demand.   Health plans should invest early in an adaptable and configurable technology platform that adapts to changing regulations with ease. Focusing on the scalability of a solution prevents health plans from having to completely replace a dated system that can no longer meet new requirements.   Changes needed to achieve reconciliation compliance can be achieved automatically, freeing resources better used elsewhere.   Establishing a system that meets the current needs of health plans with the scalability to adapt to future requirements proves daunting.  Consider outsourcing to experienced technology partners to ensure you are providing the most effective and streamlined user-experience while saving internal resources time and headaches

Softheon’s automated processes and modular solutions effectively manages all enrollment reconciliation needs while adhering to changing CMS requirements. Contact us to learn more about how our configurable, Commercial-off-the-shelf (COTS) solutions can benefit your health plan.