Reconciliation just got more complicated
The time has arrived when health plans will start receiving a monthly automated Health Insurance Exchange (HIX) 820. For most health plans, this will occur in April 2016; others, who aren’t fully ready yet, will transition in June 2016.
So all of the Finance departments throughout the U.S. should be rejoicing they do not have to populate an Excel spreadsheet on a monthly basis in order to receive payments from the Marketplace, right? Well, don’t count your chickens before they hatch, because the reconciliation processes just got even more complicated than before.
For the health plans that were part of the Marketplace from the beginning, take a step back in time with me and reflect on the exorbitant amount of issues you experienced receiving accurate membership information via the 834. Now, introduce the HIX 820 into the mix. Granted, the membership issues have slowed down a bit, however, they are still quite evident and require constant attention and documentation to ensure they don’t slip through the cracks. The HIX 820 impacts health plans that are part of the Federally-Facilitated Marketplace (FFM) and the State-Based Marketplace (SBM) since the HIX 820 handles payments for the Advance Premium Tax Credit (APTC), Cost Share Reduction (CSR), Risk Adjustment, Reinsurance, and Risk Corridor. Financial stability of organizations now relies on the accuracy of the reconciliations for the HIX 820 to make the member’s payment whole.
What health plans should be prepared to handle:
- Technology issues when translating the file to a usable format.
- Health plans that are a part of the FFM will need to conduct reconciliation between the 834, HIX 820, and the member.
- Health plans that are a part of an SBM will need to conduct reconciliation between the state enrollment information, HIX 820, and the member.
With changes in the front-end systems and operational processes, it’s important not to lose sight of the impact this data has on downstream processes. It is imperative all adjustments, updates, discrepancies, and relative information are easily tracked and accessible for the reconciliation and reporting of APTC, CSR, medical loss ratio (MLR), and risk adjustment. Membership and their corresponding payments are the backbone of a health plan. You want to ensure accurate information is reflected to prevent erroneous materials from being sent to members or to the Centers for Medicare & Medicaid Services (CMS).
How can Gorman Health Group help?
- With a best practice approach, the Gorman Health Group Reconciliation team can supplement your current staffing model with a focus on reducing your discrepancy volume enabling timely and accurate policy-based payment from the FFM and other positive, downstream impacts.
- Review and build efficiencies with your current reconciliation process
- Identify key gaps with enrollment processing and assess opportunities to reduce the volume of discrepancies (both enrollment and payment)
- Bring transparency into key measurements Issuers must pay attention to.
Valencia™
Our premier reconciliation tool, Valencia™ is the tool of choice with approximately 11M lives under management. Specific to the Marketplace, Valencia™ reconciles 4M or 31% of the 12.7M members enrolled in the FFM and SBM marketplace.
The Gorman Health Group Reconciliation team utilizes the Valencia™ application to better understand a client’s reconciliation health. The team will load the required files for comparison and summarize the discrepancy landscape. Valencia™ allows the team to work, resolve and measure productivity thereby reducing the volume of errors.
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