The Client: A Leading Health Insurance Provider

Overview

The Company’s subsidiaries and their affiliates provide a widespread range of group and individual health benefit, life and disability products to millions of members.

The Company delivers a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, pharmacy benefit management.

The Company has grown with consistency in the industry. This performance is the result of its strong internal growth, strategic expansion and a commitment to providing greater value to customers and stakeholders. As one of the largest health benefits provider, the Company has an immense responsibility towards its stakeholders.

As an aftermath of the overhaul that the US healthcare system is undergoing, several health insurance providers are reinforcing their Governance, Risk and Compliance (GRC) programs to manage their risks better, gain enterprise-wide vision and ensure complete compliance with multiple regulatory requirements and corporate policies. A number of health plans, recently responded to the rapidly changing regulatory environment by redefining their compliance strategies and redesigning the processes, systems and tools being used to support compliance programs.

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Solution

The Company needed a workflow-based solution with robust architectural capacities to reinforce its compliance management in a manner that would integrate several functions being carried out in silos.

After scrutinizing multiple options offered in the market, the Company selected MetricStream’s solution for its diverse compliance requirements. Along with MetricStream’s strong architectural capabilities, ability to support large organizations and flexibility, MetricStream team’s extensive prior experience in the health insurance space served as another key driving factor for this selection. The experience of other BCBS affiliated health insurance providers already using the MetricStream solution confirmed the selection.

MetricStream provided the Company with a comprehensive solution based on MetricStream GRC Platform with modules configured to address the Company’s specific compliance needs.

MetricStream solution provides end-to-end workflow automation across the Company’s business units and departments supporting the Company’s organizational model across all the regions and states it operates in, business units as well as their mapping to different functional roles and reporting relationships. Users have a role-based portal access with options required for initiating actions, responding to events, managing and assigning tasks, viewing reports and dashboards, limited to their roles. The system triggers email-based notifications and alerts to appropriate personnel to notify them of various events and requirements.

Regulatory alert tracking: MetricStream’s solution streamlines the regulatory workflow of the Company and supports task assignment, status tracking and reporting at every stage till the successful implementation of the regulation. The system captures every relevant regulation and allows the regulatory group at the Company to prepare legal summary of every applicable state law. The group assigns this regulatory alert to the compliance personnel of the region impacted by the law who then delegate tasks to the staff responsible for implementing the state law in their respective business units.

This module allows the Company’s regulatory group to assign and track all regulatory alerts, define and maintain a centralized structure of the overall regulatory alerts and compliance including entities, processes in scope, risks for the processes and plans, controls to address the risks and mechanism to assess the controls. The assessment plans can be designed and scheduled periodically or triggered based on occurrence of regulatory events.

Market conduct examination tracking: MetricStream system 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 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.

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 Company 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.

Accreditation: The accreditation process to distinguish health plans based on scored quality metrics requires the Company 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.

Document management: MetricStream’s solution enabled integration with content feeds to recognize changes needed in policies, customizable and scalable meta-data model and powerful search.

MetricStream’s role-based views enable the Company to make the system available to a wide band of users including external auditors and third parties with real-time read-only access to certain documentation.

The application supports check-out and check-in of documents to ensure version control. At each stage of the document, multiple authorized users can access the document simultaneously and complete their respective tasks. All the information is merged and can be viewed in completion or by filtering based on the reviewer.

To protect the security of the documentation, the access is controlled. In addition, MetricStream platform records all access and modifications within the system, including user and system data. Any records, document, or data field changes result in an auditable record. A full and complete audit trail/history is always available. Reports can then be generated to display this audit history data in the appropriate views. The entire access and edit history of a record is captured with accurate time-stamps.

Fraud and abuse/incident management: MetricStream solution provides the Company an enterprise-wide visibility into incidents, ability to distinguish case types, automated workflows to remedy incidents, and regulatory reporting. It allows tracking of fraud and abuse claims by special investigation units (SIUs) and departments from initiation to closure.

The source of the case and dollar values associated with it are captured and tracked for reporting and trend analysis. Graphical executive dashboards and flexible reports with drill-down capability provide statistics and data based on parameters such as by SIU, department, incident type, sub-type, business units, functional processes and locations.

At the time of initiation, the system captures detailed information about the case and supports categorization of incident type based on pre-defined criteria and severity level along with identification of responsibilities. Depending on the parameters, the case is automatically routed to an internal department for investigation and response. Different workflows are set up for different case types. Notifications are sent to relevant departments and personnel. Status reports as well as automated alerts allow the teams to keep track of updates and changes to cases.

Why MetricStream was Selected

MetricStream solution is workflow-based and has versatile reporting capabilities with every piece of tracked data being a reportable field and ability to create customized reports and templates to match the Company’s frequently changing reporting needs.

MetricStream solution supports several layers of downstream assignments that can be managed independently with a capability to roll information back upstream for wider reporting requirements.

MetricStream solution integrates regulatory information with the application workflow, facilitating foolproof regulatory alert tracking and management.

Along with ease of use and secure database, MetricStream solution also offers data tracking in multiple formats.

MetricStream has the ability to support large organizations and meet their varying compliance requirements as well as IT requirements in the areas of integration, configurability, scalability and security.

Challenges

Growing regulatory demands: With major changes been made to health insurance law in the United Sates, the regulatory demands for health insurers have been constantly increasing, resulting in an extremely intricate web of regulations at various levels – national, regional and state, data and information management , market segments and product offerings to mention a few.

As the pressure to comply with this complex maze of regulations began mounting, the Company required a sound program for managing and sustaining regulatory compliance, preventing fraud and abuse and managing incidents of non-compliance, among others. For instance, a major area of responsibility of the compliance unit is to ensure positive outcomes from Market Conduct Exams conducted to determine how the company operates in the market place covering - sales practices, advertising materials, marketing, policyholder services, underwriting, rating, claims handling practices. The formats and procedures of resulting corrective action plans also differ widely from state to state and pose a challenge in standardizing operations.

Stronger responsibility: With changes in the US health care system giving rise to strong accountability towards policyholders, shareholders and employees, consumer empowerment and protection featured as a mandatory part of best practices and market conduct examination reports and conflict of interest surveys acquired greater importance requiring rigorous planning , elaborate information collection and detailed data analysis and reporting.

Lack of automation: The Company was using free-form manual, paper-based processes, basic tools such as spreadsheets and e-mails and stand-alone applications for compliance related activities. As a result, the Company faced challenges in achieving effective management of information routing task for critical areas such as accreditation, documentation, fraud, abuse, incidents of non-compliance, and conflict of interest surveys.

Need to improve fraud and abuse claims management: The risk of fraud and abuse violation has increased for companies that provide benefits to Medicare and Medicaid recipients. Government programs have strengthened their activities in audit and inspection area to eradicate fraud and abuse in health insurance sector. Enhancing the management of fraud and abuse claims has acquired significant importance for the Company.

Customer Quote

“MetricStream has mapped its solution to support our specific needs and workflow structure. With this easy-to-use and flexible solution, we have achieved stronger compliance and reporting ability across organization making us better-equipped to meet the specific challenges in the health insurance space today,” says the spokesperson of the Company.

Benefits

  • Streamlined compliance:
    With automated workflow and meticulous data tracking, the Company has streamlined its compliance to applicable regulations significantly. Centralized structure of the overall regulatory alerts and executive dashboards provide real-time information on the compliance process, enabling the Company’s regulatory group to ensure compliance with regulatory and safety requirements.
  • Proactive regulatory tracking and effective management of regulatory actions:
    Integration of a huge volume of relevant regulations in the application workflow has enabled the Company to track every regulation and related actions proactively. This contrasts with the previous situation at the Company where regulatory tracking was more reactive and dependent on emails and personal communication. MetricStream solution has minimized the instances of overlooking regulatory changes or failing to act upon them.
  • Improved decision-making capabilities:
    With MetricStream’s powerful analytics and business intelligence provided by the built-in reporting engine and role-based dashboards the Company can proactively track all metrics and indices to resolve issues and take decisions based on facts and data.
  • Stronger control on fraudulent activities:
    Equipped with automated alerts, source capturing, trend analysis and dollar value tracking the Company is able to control the fraud and abuse incidents more effectively.
  • Enhanced public image:
    MetricStream’s reporting and status tracking capabilities mapped to regulator audits through various stages have led to public market conduct examination reports that speak for themselves. This has helped enhance the Company’s public image greatly in the eyes of its stakeholders and has minimized the risk of severe corrective action plans, sanctions and fines.

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