Syntel's Risk Adjustment Solutions for Healthcare Payers
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Syntel's Risk Adjustment Solutions for Healthcare Payers

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Syntel’s Risk Adjustment solution equips payers with a flexible and comprehensive tool that enables health plan data submission in regulatory formats. The solution extracts required information from ...

Syntel’s Risk Adjustment solution equips payers with a flexible and comprehensive tool that enables health plan data submission in regulatory formats. The solution extracts required information from payer systems and de-identifies, aggregates and creates files ready in the required format for submitting to the EDGE server. The solution has reporting and error resolution capabilities and addresses areas that demand immediate attention.

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Syntel's Risk Adjustment Solutions for Healthcare Payers Syntel's Risk Adjustment Solutions for Healthcare Payers Document Transcript

  • Commercial Risk Adjustment is a high-impact revenue generating process. Payers experience risk of adverse selection and risk pool failure to control enrollment of members posing high risk in a particular health plan, due to enrolments on Health Insurance Exchanges (HIX). In the current scenario, payers lack the necessary tools, expertise and know-how needed for standardizing and submitting the required data. Health Plans are ill-equipped to manage errors, reports or other miscellaneous interventions after data is processed on EDGE server. Payers need to submit enrolment and claims data in the Department of Health and Human Services (HHS) specified format to the EDGE server. The EDGE server performs risk adjustment calculations for HHS to reimburse payers. This however, exposes the members from the high-risk segment to risk hazards, leading to revenue loss. Risk Adjustment data submission necessitates increased focus for mitigating the financial risks associated with HIX. Payers are also finding it difficult to establish data collection processes for HHS risk adjustment operations. Healthcare Payers’ Risk Adjustment Data Submission Solution in HIX Syntel’s Solution Syntel’s Risk Adjustment solution equips payers with a flexible and comprehensive tool that enables health plan data submission in regulatory formats. The solution extracts required information from payer systems and de-identifies, aggregates and creates files ready in the required format for submitting to the EDGE server. The solution has reporting and error resolution capabilities and addresses areas that demand immediate attention. Our solution’s unique approach includes: • Data extraction: Our Extract-Transform-Load (ETL) tool helps smooth extraction of relevant core system data elements for streamlined RA data submission workflows • Database staging: Staging database is built to extract member data from payer core systems and third-party vendors for standardization and integration. This step enables ETL routines and subsequent error resolution processes • XML creation: Our XML tool de-identifies and aggregates data elements in the HHS specified format, and creates an XML file • Pre-submission checks and data submission: XML is verified to ensure first-pass processing and then submitted to the EDGE server Risk Adjustment Data Submission Process For more information, visit Syntel online at www.syntelinc.com or call us at US/+1 (248) 619-3503, UK/+44 (0) 207-636-3587 © 2014, SYNTEL INC. 052014 Enrolment Medical Pharmacy Claims - Data ETL Tool Staging Database De-identify Aggregate XML Generation HHS specified format Rejected Data Error Resolution EDGE Server HHS/CMS XML Tool
  • For more information, visit Syntel online at www.syntelinc.com or call us at US/+1 (248) 619-3503, UK/+44 (0) 207-636-3587 © 2014, SYNTEL INC. 052014 Healthcare Payers’ Risk Adjustment Data Submission Solution in HIX • A leading global IT and KPO service provider • Established in 1980 (NASDAQ: SYNT) • 30 offices in North America, Europe and Asia • A flexible offshore-onsite global support model with 24x7 support services • Good mix of functional and technical experts - We are committed to delivering service-oriented solutions that generate desired business results WHY SYNTEL? Solution Benefits • Faster time-to-market: Pre-configured steps and processes for specific core systems resulting in faster implementation: • Payers with Facets as their core systems have a partially complete ETL process for integration whereas rest of the solution is pre-configured • Payers using other core systems have Staging DB, XML tool and Reporting UI pre- configured, reducing the ‘go-live’ time for HIX submissions • Efficiency and accuracy: Streamlined data submission operations for XML creation • Cost savings through risk adjusted reimbursements: Improved financial reimbursement processes with first-pass processing reduce the risk of fine and penalties Syntel Differentiators • Pre-configured accelerators reduce efforts and labour hours for ETL routines and XML creation • User friendly interface for easily viewing reports and making the required decisions • Integrated IT and KPO services for resolving errors to minimize adverse financial impact • Deep industry know-how helps the Payer Practice R&D group with subject matter experts, AHIP-certified business process advisors, certified professionals and business analysts • Proven expertise and rich experience of working with leading payers