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Life Health > Health Insurance > Health Insurance

Health IT exec hates silos

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Another in a series of interviews with people who are knee deep in the PPACA World ocean.

Sumit Nijhawan says federal regulators ought to make it easier for health insurers to re-use big Patient Protection and Affordable Care Act data reporting efforts.

Nijhawan is chief executive officer of Infogix, a company that helps health insurers and other companies glue the contents of databases together and validate the completeness and accuracy of the merged data.

The company also offers systems that companies can use to control processes and operations. In the health insurance market, it’s offering those systems as tools for customers that want to present information in a consistent, standardized information; run health plans subject to PPACA; and create reports for the PPACA medical loss ratio and PPACA “three R’s” risk-management programs.

In the health plan administration field, for example, Infogix is helping plans with “cost-sharing reduction collections” — getting the federal government to pay its share of the deductible, co-payment and coinsurance costs for moderate-income consumers who buy certain health plans through the PPACA public exchange system.

Congress created the cost-sharing reduction program to make sure that workers with incomes from 133 percent to 250 percent of the federal poverty level could use the private health insurance bought through the public exchanges without fear of having to pay enormous out-of-pocket costs.

Almost all health insurers have to deal with the PPACA MLR and risk-management programs, and any selling “qualified health plans” through the public exchanges have to deal with cost-sharing reduction reporting, Nijhawan said.

The cost-sharing reduction data and some of the risk-management program reports, such as the reinsurance program report, have to be very detailed, Nijhawan said.

The MLR reports are much more general.

This spring, insurers will be filing reports for the 2013 plan year. Insurers also filed PPACA MLR reports for the 2011 and 2012 plan years.

But, even if an insurer has spent the money to set up and perfect its MLR reporting system, it is also has to set up similar but separate cost-sharing reduction and three R’s reporting systems, Nijhawan said.

Many insurers have the teams responding to the PPACA data demands in separate silos, Nijhawan said.

Meanwhile, Nijhawan added, the teams at the Centers for Medicare & Medicaid Services seem to be developing the PPACA reporting systems in silos of their own.

“As far as I’m concerned, CMS is just a giant carrier,” Nijhawan said.

Nijhawan sees another, related problems: Carriers assuming that, because PPACA plan enrollment has been lower than expected this year, they can administer the plans with manual systems, rather than trying to automate the process.

Nijhawan said he thinks insurers that use that administration strategy will suffer if the PPACA plans get any bigger.

“Once the volume goes up, it’s going to hit them,” Nijhawan said. “They can’t possible do this manually.”

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