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January 08, 2014 at 08:42 AM
Much has been made of the incredible complexities involved with the Patient Protection and Affordable Care Act (PPACA).
As one might expect when the government gets involved in something that was formerly the province of the private sector, the processes, procedures and penalties attached to the fairly simple desire to provide all Americans with protection against illness and injury are quite Byzantine.
Yet when you strip away all the specifics and reams of legislative elaboration, the ability of health insurance payers to successfully turn reform into revenue hinges on one thing: data integrity.
As in the proverbial rhyme, where a missing nail sets off a chain of events that ultimately topples a kingdom, a faulty enrollment system, an erroneous entry or even a decimal point out of place can have dire consequences on members’ abilities to receive accurate quotes or enroll in the program (as we have already seen).
All of which leads to customer dissatisfaction from what the payer hoped would be a new and lucrative revenue source. At the same time it can also severely hinder payers’ abilities to receive subsidies on a timely basis, turning what should’ve been a payer’s dream into a logistical nightmare.
Let’s look further into how the data integrity nail can affect the PPACA kingdom.
The challenges of integrating new channels
One of the biggest issues PPACA has created for insurance payers is a loss of control over the way enrollments, payments, member communications and just about everything else is processed. Under normal circumstances, the health-care payer controls the way systems are set up and the way data is entered into it. When an invoice for the premium is issued to the insured, it’s either paid or not paid.
Health care payers that want to take advantage of the opportunities in PPACA now have to integrate these new channels into their existing sales and enrollment process. The way that data comes in may not be immediately compatible with their existing systems, in which case adjustments will have to be made. Data may come at different intervals than they’re used to as well, which doesn’t fit their processing or billing cycles.
There’s also a risk that payers won’t know these new members in the same way they know their current members, because they’re not able to capture the same level of detail they do now. Members enrolling through the exchanges will only be required to fill in the information the government requires.
What payers have is a disconnect between the way health-care payers are used to working and the way they’re required to work under PPACA. When that occurs, critical data – data that must be entered in order to complete enrollment, approve doctor visits, process claims, produce accurate invoices, etc. – can slip through the cracks. And incomplete paperwork anywhere along the chain means a delay in getting paid, a potential loss of revenue, and loss of those members they fought so hard to win initially.
The natural reaction is to say, “If there’s a problem, we’ll fix it.” How much effort can it take to find one nail?
The challenge is it’s not one nail. Once the front-end website problems are resolved, PPACA is expected to deliver a glut of data from millions of members. If there are issues on how data are incorporated into the health-care payer’s systems, it could mean millions of individual data integrity issues.
Depending on how big a mismatch there is, resolving them using manual means could require an army of auditors correcting each record, one-by-one. And the longer it takes, the more payers are exposed to a loss of customers (either through customers dropping due to dissatisfaction or the payer dropping the customer thinking there is a problem that doesn’t actually exist), revenue and credibility.
