Case Study

Blue Cross Blue Shield Affiliates Adopt an Integrated Approach to Intensify Overall Compliance, Risk and Audit Management

The Blue Cross and Blue Shield Association (BCBSA) is a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies that provide high-quality, affordable health insurance.

The healthcare industry has witnessed sweeping regulatory reforms over the last few years. From the Affordable Care Act to the Model Audit rule (NAIC MAR), OIG Corporate Integrity Agreements (CIA), HIPAA, Market Conduct Examinations, Code of Conduct and Quality Accreditations to other mandates from the Centers for Medicare & Medicaid Services (CMS), compliance regulations have only increased in scope and number. With intense regulatory scrutiny and high noncompliance penalties, health insurance providers need to step up. A robust compliance program can lower the incidence and impact of risks, help overcome crisis and build higher brand loyalty.

Uncompromising integrity to build trusted relationships with members and the communities it serves is of utmost importance to them. Compliance with all relevant regulations is mandatory for BCBS members to maintain its leadership in corporate governance standards and ethics.

Driven by the mission to provide access to quality healthcare, BCBS affiliates are committed to developing a world-class audit, risk and compliance management framework. As the number of compliance requirements increased, the members needed a robust and integrated system that could strengthen the company's existing compliance strategies, mitigate risks and protect the interests of patients.


The BCBS affiliate companies that MetricStream was engaged with were all looking for an integrated solution to drive a sustainable compliance-focused organizational culture. The solution was required to manage their complete compliance and audit programs as well as support each organization's regulatory commitments and manage issues effectively on a common platform.

After scrutinizing several compliance solution providers, MetricStream was selected based on its holistic approach to compliance, audit, risk and issue management, its domain expertise and rich solution capabilities, as well as its successful track record in the health insurance industry.

MetricStream provided these BCBS affiliates with a comprehensive, integrated solution, equipped with capabilities for complete audit management, regulatory alerts tracking, policy management, and issue management. The solution assures them complete compliance with regulatory requirements, thus boosting stakeholder confidence and protecting the interests of their policy holders.

Compliance Management

MetricStream Solution enables the BCBS affiliates to comply with the complete range of healthcare-related regulations, including NAIC MAR and CMS mandates. With MetricStream Solution, the organizations can ensure complete compliance not only with health insurance-specific mandates, but also with cross-industry mandates such as the Sarbanes-Oxley Act, PCI, FCPA and several others.

The solution provides a centralized structure to the overall compliance and control hierarchy, including processes in scope, risks for the processes, controls to assess the risks and mechanisms to assess the controls.

At each point, control assessments are easily scored, tabulated and reported. They are also monitored based on predefined criteria and checklists.

The solution contains powerful reporting capabilities to aggregate control assessments and compliance data into comprehensive reports. It enables the BCBS affiliates to track compliance patterns, study and analyze compliance trends, and focus on those areas that require immediate attention.

Regulatory Alerts Tracking

MetricStream Solution seamlessly integrates with regulatory sources such as CMS and the Health Plan Management System (HPMS) and captures and collates requirements and regulatory information, industry guidance, national governance, laws and regulations on a central platform. The compliance managers at the BCBS affiliate companies were able to access an exhaustive compliance library within the application, identify relevant regulations, document specific requirements for their organizations, and define a monitoring process to comply with requirements.

This helps the BCBS affiliates track regulatory updates through various channels such as the Web, e-mail and RSS Feeds. Subsequently, the solution helps in interpreting these alerts and updates, keeping stakeholders informed and initiating an issue and action plan.

Policies and Procedures Management

MetricStream policy and procedure management solution provides the BCBS affiliates a flexible framework to streamline the creation and management of policies and procedures in line with applicable regulations. This helps the companies encourage accountability and communication within their compliance teams.

The solution has introduced an electronic and automated approach to the development, maintenance, and communication of policies and procedures for the BCBS affiliates across enterprise, along with a central repository to store and organize policies and procedure documents. Integrated collaboration and workflow tools can be used to access, create, modify, review, and approve policy and procedure documents globally in a controlled manner.

Built-in tools support policy implementation, acceptance, exception tracking and mapping of policies to compliance requirements. The detailed analytics and reporting capability with graphical dashboards tracks each policy from origin to obsolescence, giving managers complete visibility into the system.

MetricStream solution enables the BCBS affiliates to integrate policies and procedures with the compliance, risk and control framework. At each section and sub-section of the policy, risks and controls can be linked.

Risk Management

MetricStream deployed an integrated and flexible risk management framework for documenting and assessing risks, calculating inherent and residual risk scores, defining controls, control assessment, identifying issues and implementing recommendations and remediation plans. The risk management solution includes powerful tools for risk analysis and for monitoring such as configurable risk calculators and risk heat maps. Embedded content about risk management best practices helps the BCBS companies define the scope of processes and sub-processes for which risk management needs to be performed and guides the development of control and test libraries.

Audit Management

MetricStream Solution provides end-to-end functionality for managing the complete audit lifecycle including audit planning and scheduling, development of standard audit plans and checklists, field data collection, development of audit reports and recommendations, review of audit recommendations by auditees and management and implementation of audit recommendations and remediation.

Audits can be scheduled periodically or on an ad-hoc basis for internal departments, processes and projects. Based on the master audit calendar, the scheduler can select a team of auditors and assign the audit responsibility with a due date.

Auditors can define checklists and tasks that need to be performed for audit. Checklists can also be downloaded and used offline with the Offline Briefcase option. The solution helps in recording audit results indicating conformance or non-conformance, flagging critical failures, triggering and tracking action plans.

Market Conduct Examination Tracking

MetricStream Solution provides comprehensive capabilities for identifying the governing regulations, providing complete compliance evidence, tracking evidence status, policies, standard procedures associated with regulator audit. The solution allows appropriate staff to access the examination notification received from the regulator. Based on the pre-audit questionnaire, the BCBS staff is able to assign tasks and obtain documents and information with due dates and track open assignments.

The solution supports the documentation and preliminary reporting. The staff is able to consolidate the records and send for regulator's preliminary review. Certain sections of the report can be flagged as confidential and shared only with appropriate users. The system automatically generates mandatory reports in prescribed formats and layouts.

The solution also supports post-examination stipulation and corrective action implementation. It allows the Company's staff to upload and notify stipulation, or certain portions of it, to appropriate members for review based on entities impacted. The system provides the capability to configure and execute certifications based on predefined templates and schedules for designated executives. The result of the follow-up task is routed back to the appropriate executives for approval and final closure of the case.

Issue Management

MetricStream solution helps compliance groups at the BCBS affiliate companies to track, investigate and resolve sensitive noncompliance and other issues. The solution enables the companies identify and rectify discrepancies, gaps, coding errors and other issues related to audits as well as other enterprise wide GRC issues. It allows tracking of fraud and abuse claims by special investigation units (SIUs) and departments from initiation to closure.

The system assigns a unique ID to each issue which makes it easy to track the issue across review stages. Issues are categorized based on predefined criteria and detailed information about each issue is provided.

Failure investigations are conducted to determine the root cause of the issue. The investigation is conducted using collaborative workflows. Remedial action is facilitated by automatic alerts and notifications which are sent to the appropriate personnel. Corrective action is initiated and the case closes when the action plan is implemented.

All issues including potential noncompliance issues trigger the issue management and remediation mechanism. The system then investigates, analyzes and documents the issue, and routes it to the required personnel for further investigation. At every stage, executive dashboards allow managers to closely track the issue as it moves from one stage to the next.


The accreditation process to distinguish health plans based on scored quality metrics requires the BCBS companies to complete the process on time and with precision.

MetricStream provides a repository to store, organize, assess and submit accreditation and compliance documentations such as case records, operating procedures, meeting minutes and other documents to agencies and regulators in a streamlined manner. Submissions can be periodic or event-based and support reporting formats and data exchange standards. The records can be organized and grouped in a logical fashion with the ability to create any number of sub-categories and tree-like hierarchies.

Interfaces with NCQA's Interactive Survey System (ISS), the web-based tool for health plan accreditation, are provided to facilitate submission to the accreditation entities.

Self assessments can be triggered to conduct mock-reviews on compliance documentation and audit-readiness. The system provides the capability to configure and execute surveys and self-assessments based on predefined templates and schedules for designated executives. Each element can be scored, with recommendations inserted as appropriate.

MetricStream provides capabilities to manage and submit evidence documentation online using various data exchange standards.

Conflict of Interest Surveys

MetricStream has integrated its application with PeopleSoft ERP system in order to facilitate extracting and synchronizing associate data and organizational data of the BCBS companies for activities related to conflict of interest surveys such as distribution to relevant individuals, verification of all attestations, identifying issues for further investigation, investigating and resolving any conflicts of interest that are identified. The solution allows customization of questionnaires, scalable document storage, secured access to system, ad-hoc querying and reporting capability.

Automated email notifications are distributed to associates with a link to their specific questionnaire. The questionnaires can be organized and grouped as desired. A library of questionnaires is maintained with appropriate metadata for each questionnaire. Confidentiality setting can be configured to hide the associate details.

The system supports attaching and storing related records such as mitigation plans, reports, evidence, attestations and samples. The solution supports data retention for all survey records for a specified period as well as data archiving.

MetricStream GRC Platform

MetricStream solution is built on an integrated GRC platform allowing the BCBS affiliates to extend the solution across business units, operations, departments and geographies. The platform provides built-in tools such as a Form, Process Flow and Data Designer and helps configuring applications to suite specific business requirements. It helps these organizations to automate, streamline and integrate compliance management across their enterprise.

The platform also enables them to adopt a unified approach to compliance by breaking down restrictive silos and building more collaborative workflows. It provides a centralized framework to manage all compliance processes ranging from regulatory tracking, assessing controls, monitoring, issue management, risk analysis, to reporting and documentation.


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