Ensuring Compliance with the Affordable Care Act
Trexin worked with a large healthcare Payer to develop a solution that met the requirements for compliance with the Affordable Care Act.
Business Driver
Our Client, one of the largest healthcare Payers, needed a comprehensive solution to comply with the requirements for submitting healthcare data to the U.S. Department of Health and Human Services (HHS) that would go into effect as a part of the Affordable Care Act (ACA).
The VP of Valuation and Management Reporting asked Trexin to build the following:
- Design and implement a strategic data warehouse that would bring together claim, membership, and plan data.
- Create a semantic layer that would ensure the data could be submitted to HHS with an acceptance rate of 93%
Approach
Trexin fielded experts across several disciplines to work on developing the solution:
- Program management
- Strategy and data architecture
- Data analysis, acquisition, and assurance
We worked closely with our Client’s business leaders, subject matter experts, and IT staff to clearly define the business requirements, and then we designed a successful prototype that demonstrated how our Client could both comply with the new government regulations and strengthen their business model in the individual and small group markets.
Trexin then developed the claims repository in the form of an atomic data warehouse and consolidated data from five different issuers. We then developed the semantic layer using IBM’s Health Plan Data Model (HPDM) as a foundation and enhanced it based on deep analysis of the regulatory requirements and Payer data related to members, plans, medical claims, and pharmacy claims.
Results
After implementing Trexin’s solution, our Client completed the data submission to HHS in full compliance with the ACA regulations, and 99.2% of claims were accepted. They also realized a return of almost $1B based on claims paid in 2014 through the reinsurance and risk adjustment programs.
