Case Study 8.2.2013

Ensuring 3R Compliance with the ACA

Trexin helped a large payer prototype a solution for ACA Reinsurance, Risk Corridor, and Risk Adjustment requirements

Business Driver

In March 2010 the federal government regulated comprehensive healthcare reform through passage of the Patient Protection and Affordable Care Act (ACA). While some provisions of the law have already taken effect, many more will be implemented in the coming months as the law significantly changes the way healthcare companies will do business. One part of the ACA is a series of risk-spreading programs commonly referred to as “3R” (for Reinsurance, Risk Corridors, and Risk Adjustment), which is intended to mitigate the impact of potential adverse selection and stabilize premiums in the individual and small group markets as insurance reforms and exchanges are implemented. With these 3R regulations targeted to go into effect in 2014, a top-5 healthcare payer engaged Trexin to help it develop a prototype of its 3R solution.

EnsuringComplianceACA300-01

Approach

Trexin’s approach to addressing this disruptive change centered on studying the regulatory requirements and using a “one set of facts” process approach to build upon our existing expertise of the healthcare payer business, systems, and data. Working closely with business leaders, subject matter experts, and IT, Trexin defined the detailed business requirements and then designed, developed, and tested a 3R prototype solution. The Trexin team built the prototype utilizing IBM’s health plan data model and ETL tools, combined with a deep understanding and analytical analysis of the regulatory requirements and payer data related to members, plans, medical claims, and pharmacy claims. The prototype implementation team fielded by Trexin included experts in healthcare, regulation & compliance, program management, and analytics (including data architecture, data modeling, and data integration).

Results

Because of Trexin’s specialized knowledge of the ACA 3R requirements and our proven track record of being able to deliver actionable healthcare expertise, the 3R prototype successfully demonstrated how our Client could not only comply with the new government regulations but also strengthen their business model in the individual and small group markets. In recognition of these results, our Client has subsequently asked Trexin to help design and build their 3R production solution.

Tagged in: Data & Analytics, Healthcare
Social Media Accounts