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Amid Exchange Sustainability Challenges, Softheon Introduces Profit & Loss (P&L) Business Intelligence for Insurance Carriers

STONY BROOK, N.Y. December 10, 2015 – Softheon, a proven leader in cloud-based health insurance marketplace integration and a certified Web Broker Entity, has announced the availability of big data and business intelligence capabilities within Softheon Marketplace Connector Cloud (MC2). P&L analysis is based on enrollment, premium billing, and claims data that Softheon MC2 collects and processes as part of daily operations and compliance reporting. Softheon has developed the real-time data-driven solution to address insurance carriers’ challenges in order to better understand, not just member acquisition, but also utilization. Therefore, closing the loop with valuable feedback for actuarial processing.

With claims, enrollment, and payment data under one repository, Softheon is uniquely positioned to provide data analysis for financial oversight and sustainable business operations. Softheon provides health insurers with more than just a large spreadsheet of miscellaneous information, instead, Softheon’s executive dashboard brings a true visualization of P&L analytics by including:

  • Member demographics (male vs. female)
  • Age band (18-35 vs 55-63)
  • County and Zip code geographical distribution
  • QHP HIOS plan (most or least profitable ACA plan)
  • Distribution channel (On vs Off Exchange)
  • Broker book of business (profitability by demography or QHP)

All P&L reports provide drill down analytics with options to view data at a quarterly, monthly, and daily level, whereby insurers can determine the plans that contribute the least amount of revenue, etc. Claims analysis also reveals trends towards better utilization management, fraud, waste, and abuse anomalies among the providers with high claim payout for the same ICD/CPT code.

“The data-driven business model is critical to the success of insurers in exchanges as it was evident in recent announcements from carriers exiting ACA or shutting down. However, with our P&L Business Intelligence, we are able to quickly identify risk, such as providers charging as much as 8 times for the same ICD/CPT code, in real-time,” saidEugene Sayan, Softheon CEO & Founder.

Softheon not only provides insight into the data, but also delivers feedback to carriers to help them utilize the given information to increase profitability in areas of low revenue. Softheon’s team has found that some providers are charging over four times more than other providers for the same service. They have also identified October to be the month with the least net revenue despite observing a peak in overall claims.

“Across all industries, organizations have been changing the way they approach big decision making as a result of big data or analytics. However, despite its immediate benefits towards building sustainable exchange operations, building a big-data repository and surrounding business intelligence, can be a daunting task- if not a major challenge when attempting to building internally and using existing technology and process. Big data and analytics are in the DNA of our cloud platform, not just an extension of what we do.” added Sayan.

According to PwC, 80% of Global CEOs say data mining and analysis is “strategically important to their organization.” About 52% of senior executives say they have previously discounted data that they do not understand, where 31% say the timeliness of data at their organization is poor or fair, and 25% of senior executives claim that they lack the skills or expertise to make greater use of data.

About Softheon

Empowering the nation’s first state health benefit exchange since 2008, Softheon’s vision and strategic direction address healthcare payer, provider, and government agencies’ goal of meeting Affordable Care Act (ACA) milestones. Softheon provides HIX Integration, Direct Enrollment, Premium Billing, and Edge Server solutions for insurance carriers of all sizes participating in Federal and State Health Insurance Exchange (HIX) Marketplaces. Softheon’s Marketplace Connector Cloud (MC2) has been trusted by health plans in all 50 states as an accelerated federal, state, and private exchange integration platform. Softheon MC2 is a Software-as-a-Service (SaaS) solution where insurers pay a one-time activation and ongoing PMPM fees for exchange members only, while eliminating most, if not all, risks associated with ACA enrollment compliance and other mandates.

To learn more about Softheon’s solutions, visit or email

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