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PPACA and data integrity

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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.

One additional complication is that payers are not looking at a set of rules and regulations that are set in stone. Instead, compliance with the data requirements under PPACA is and always will be a moving target. That means health-care payers have to ensure that whatever they do, their systems are agile enough to adapt to whatever happens in the future.

It is likely that PPACA will be a political football for some time. If payers are locked into one way of doing things that’s difficult to adjust, they may find themselves spending far more to achieve compliance than they should.

Integrity through standardization and automation

Those are the core issues, and they are many. Fortunately, the solution to most of them comes down to two key concepts: standardization and automation.

One of the first steps health-care payers will want to take to ensure data integrity is to collect and aggregate data in a standardized way. In other words, whether payers are working with new members via the various health information exchanges, email, phone, regular mail or some other method, payers will want to do everything they can to ensure it is collected and communicated the same way for all.

The more payers can standardize up front, the less work they’ll have to do to reconcile the information later when timeliness becomes even more of a factor. Wherever possible, the system should prevent data from being submitted until all the required information is present and correctly formatted.

The second part is to replace manual processes wherever possible with automation. An automated system will ensure the integrity of the data while greatly accelerating the flow of work.

Consider enrollment again. Let’s say you’re at XYZ Insurance, and you have 1,000 enrollments coming in each day. If you’re using manual processes, you will need enough people to check each and every one of them to be sure they are complete, accurate and compliant. If the number suddenly jumps to 2,000 a day, you’ll need to double that number (or close to it).

With an automated system you can manage by exception. The system will compare each enrollment to what your system requires and your business rules, and flag any that are incomplete or inaccurate. If there are problems with three enrollments, a human being will only need to look at those three instead of the other 997 – or 1,997. You’ll be devoting far fewer resources to checking data, which means you can dedicate more to helping members actually enroll.

Something else to keep in mind, of course, is that enrollment is just one horse in the army. As other aspects of PPACA come into play – member payments, government subsidies and reconciliations, doctor visits, claims, etc. – the challenges of ensuring data integrity will multiply exponentially.

Think beyond the point

With so much happening so fast, there is a tendency for organizations to focus on finding a point solution for whatever is vexing them today. While that may solve today’s challenge, it may not help a payer much with the next iteration. That means the payer will again be scrambling (and paying) for new solutions at each phase.

It makes more sense to think beyond the point to find data integrity technology that is flexible enough to address the broader gamut of issues the payer will face down the road, as well as today’s immediate issues. Doing so will allow the payer to amortize its investment across multiple areas as well as ensuring complete integration between the various components of your PPACA operation.

Of course, while the technology is important, the payer also needs to make sure it has the right teams and business processes in place. Anticipating needs rather than reacting to them is the key. The more prepared a payer is across the board, the better the payer will be able to achieve your revenue expectations while minimizing problems – and additional labor costs.

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