The Evolution of Healthcare.gov — It’s Time to Play Ball!
Now that the Federally-Facilitated Marketplace (FFM) is paying Issuers directly from the FFM system versus the Issuer’s system, we are participating in a different type of ball game. Issuers now need to shift gears and begin thinking about how they can impact a timely and accurate payment of Advanced Premium Tax Credit (APTC), Cost Sharing Reduction (CSR), and User Fee (UF) charges. Two key areas are at play here: the reduction in tracked discrepancies and ensuring action is taken to resolve and apply consumer data corrections to the FFM system to be in sync. As Issuers react to the May payment cycle and prepare for June payment, they are beginning to think about their overall payment strategy from this point on.
When considering the Issuer’s role, the days of not establishing the necessary resources to research and resolve all discrepancies simply because the volume is too high will not suffice during an audit or bring revenue in the door either. So when we talk about an overall payment strategy, it is important for Issuers to recognize they are playing on the team responsible for tracking, fixing, and overseeing their reconciliation program, which includes building an expected payment and outstanding payment based on data cleanup that is pending.
Bringing transparency to the FFM model is the first step towards alignment of data between the Issuer and the FFM and true reconciliation. Imagine being able to discuss with your government partners the substantial payment impact your organization is experiencing simply because the FFM has not applied all outstanding data corrections. That phenomenon is actually occurring today. Since January 2016, the FFM suspended the application of field-level corrections to the FFM system until this month. Issuers should finally see six months of updates reflected in their July payment and are working towards quantifying what that impact will be.
As the FFM model continues to evolve, Issuers are still working towards solving their own challenges:
- Lack of strategy for timely and accurate payment of APTC, CSR, and UF charges
- Unmanageable volume of discrepancies and inability to prioritize
- Backlog of submitted disputes and delays with the Marketplace updating system corrections
- Struggling with measuring and managing the chaos
- Missed revenue opportunities
- Not audit ready
Based on the importance of being in sync with the Marketplace — both FFM and State-Based Marketplaces (SBMs) — Gorman Health Group (GHG) has launched a new reconciliation service with a focus on reducing the volume of enrollment and payment discrepancies while building best practices within Issuers’ Finance and Enrollment departments. Now that discrepancies represent real dollars, the stakes are high.
Through GHG’s Marketplace reconciliation services, Issuers will be able to track and resolve enrollment and payment discrepancies and quantify the financial impact of those reconciliation efforts. GHG’s reconciliation experts will equip Issuers with the knowledge to predict their payment (prospective and retrospective) each payment cycle and build a process to react when the actual payment is not what your organization expected, either through a submitted dispute or internal update.
Our proprietary tool, Valencia™, which currently reconciles 42 percent of the 12.7 million Marketplace enrollees, supports clients’ reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia™ provides compliant and transparent workflow to ensure your operational processes — and the resulting payment — are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.
To learn more about the GHG’s reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.
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Gorman Health Group has launched a new reconciliation service with a focus on reducing the volume of enrollment and payment discrepancies while building best practices within Issuers’ Finance and Enrollment departments. Now that discrepancies represent real dollars, the stakes are much higher. Visit our website to learn more >>
With Gorman Health Group’s Valencia™, you’ll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments. You’ll also have complete control of rigorous, compliant and transparent workflow controls that complement your enterprise system. Set up a demo today >>
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