CASE STUDYMetricStream BLUE CROSS BLUE SHIELD AFFILIATES ADOPT AN INTEGRATED APPROACH TO INTENSIFY OVERALL COMPLIANCE, RISK AND AUDIT MANAGEMENT Customer 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. Being among the largest employers in the U.S., BCBS affiliate companies provide healthcare coverage in all 50 states, the District of Columbia and in Puerto Rico. Overview The healthcare industry has witnessed sweeping regulatory reforms over the last few years. From theBenefits 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 man-Complete compliance dates from the Centers for Medicare & Medicaid Services (CMS), compliance regulations have onlyMetricStream’s enterprise-wide compliance increased in scope and number. With intense regulatory scrutiny and high noncompliance penalties,framework along with regulatory alerts integration health insurance providers need to step up. A robust compliance program can lower the incidence andand automated control management enables BCBS impact of risks, help overcome crisis and build higher brand loyalty.affiliates to ensure complete compliance with a rangeof regulatory requirements including NAIC MAR andCMS. MetricStream solution eliminates compliance Uncompromising integrity to build trusted relationships with members and the communities it servesgaps and inconsistencies at every step, ensuring a is of utmost importance to them. Compliance with all relevant regulations is mandatory for BCBSfool-proof approach to compliance. members to maintain its leadership in corporate governance standards and ethics.Automation and streamlining of critical workflows Driven by the mission to provide access to quality healthcare, BCBS affiliates are committed to devel-MetricStream Solution eliminates the need for manual oping a world-class audit, risk and compliance management framework. As the number of complianceprocesses, spreadsheets and paper-based applica- requirements increased, the members needed a robust and integrated system that could strengthentions. The solution is equipped with the business the company’s existing compliance strategies, mitigate risks and protect the interests of patients.intelligence to automatically track regulatory updates,monitor internal controls and raise alerts when issuesoccur. This improves the efficiency of compliance Challengesmanagement processes at BCBS affiliate companiesand saves them valuable time and effort. Manual tracking of regulatory updates With the constantly changing regulatory requirements, the BCBS members had to keep up with allMetricStream Solution has provided a single point of updates and regulatory alterations. Manual spreadsheets, emails and paper-based processes werereference for a number of complex and intertwined used to track these updates and to keep the respective managers across the enterprise informed. Theprocesses and brought together compliance, risk andaudit initiatives. The solution has thus integrated and process was time-consuming, laborious and prone to human error. It was impossible to ensure that allstreamlined these processes at enterprise level for updates across all required regulations were being tracked at all times.multiple BCBS affiliates. Growing number of compliance requirementsClear visibility and corrective action planningOngoing structured reporting and communication As large health insurance providers, BCBS affiliates were faced with a constantly increasing numberwith the senior management, along with the automa- of compliance regulations including NAIC MAR, HIPAA, the Affordable Care Act and other CMStion of compliance management processes, has regulations. These regulations involve complex requirements and demands. As an example, NAICprovided the staff, senior managers and the board MAR alone, demands compliance with over 500 requirements. Complying with large numbers ofof directors at the BCBS affiliate companies a clear requirements is an extremely cost-intensive, time-consuming and arduous process, not to mentionvisibility into its risk and compliance activities. error-prone in its manual form.Powerful dashboards deliver enhanced, real-time vis-ibility at every stage, enabling the companies to make Changing face of healthcareinformed decisions regarding compliance. Health care in the United States has undergone a dramatic change resulting in higher responsibility for insurance providers, sharper focus on policy holders, more stringent and ever-changing quality andReadiness for future compliance requirements compliance demands. Adapting to the new approach and building a culture of stronger accountabilityBy analyzing trends and risks based on frequency requires an overhaul with changes at multiple levels.of occurrence, identifying high-risk areas quickly,documenting the scope of controls in a structured Overlapping compliance initiativesmanner, identifying and testing controls, many BCBSaffiliates can now continuously monitor and improve Compliance requirements were being managed through functional silos and ad hoc systems at manythe control environment and support the changing BCBS affiliate companies. Due to limited collaboration across units, departments and locations, com-regulatory requirements. pliance activities often resulted in redundancies and duplication of data.The solution enables the BCBS affiliates evolve alongwith the compliance landscape and respond proac-tively to future changes in regulatory requirements.
MetricStreamImproved enterprise efficiency SolutionComplete workflow automation by MetricStreamSolution, its integrated architecture and systematic, The BCBS affiliate companies that MetricStream was engaged with were all looking for an integratedguided workflows helped the BCBS affiliates to eradi- solution to drive a sustainable compliance-focused organizational culture. The solution was required tocate repetitive processes, unnecessary steps, and manage their complete compliance and audit programs as well as support each organization’s regula-duplication of work. The saved time and effort was tory commitments and manage issues effectively on a common platform.channelized to other high-priority activities, contribut-ing greatly to the overall increase in the efficiencyand productivity of the enterprises. 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 solu- tion capabilities, as well as its successful track record in the health insurance industry.Cost savingBy standardizing the compliance managementprocesses, MetricStream has put into effect a con- MetricStream provided these BCBS affiliates with a comprehensive, integrated solution, equippedsistency across each organization and has eradicated with capabilities for complete audit management, regulatory alerts tracking, policy management, andredundant steps at multiple levels saving the BCBS issue management. The solution assures them complete compliance with regulatory requirements,affiliates considerable costs. 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 orga- nizations 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 compli- ance 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. Policy and Procedures Creation, Distribution, Acceptance Risk Assessment Corrective Action Plan Qualitative and Quantitative Proactive & Reactive Chief Compliance Officer Oversight Audit Management Managing Controls Defining, Assessing, Re-aligning Training Program Management
MetricStream 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 infor- mation, 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. Role Action Regulatory Affairs Capture Alert Details Review Alert + Provide Attorney Feedback Regulatory Affairs Define & Assign Tasks Legal Entity CAP Work on Task + Define Review Actions Close Tasks Actions Functional Entity CAP Complete Actions Regulatory Oversight Review Tasks Review Alert & Certify Alert Closed 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 appli- cable 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 com- pliance, risk and control framework. At each section and sub-section of the policy, risks and controls can be linked.
MetricStream 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 calcula- tors 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 as- sociated with regulator audit. The solution allows appropriate staff to access the examination notifica- tion 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 notifi- cations which are sent to the appropriate personnel. Corrective action is initiated and the case closes when the action plan is implemented.
MetricStream Capture Incident Incident Manager COMMUNICATE Analyze, Validate & Assign Approve & Close Investigators Investigate Remedial Action Department Heads Senior Management Monitoring , Reporting & Analytics 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. Accreditation 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 com- pliance 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 accredita- tion, 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 vari- ous data exchange standards.
MetricStream Conflict of interest surveysWhy MetricStream MetricStream has integrated its application with PeopleSoft ERP system in order to facilitate extract- ing and synchronizing associate data and organizational data of the BCBS companies for activitiesMetricStream has vast domain experience of imple- related to conflict of interest surveys such as distribution to relevant individuals, verification of allmenting GRC solutions for some of the largest health attestations, identifying issues for further investigation, investigating and resolving any conflicts ofinsurance companies. interest that are identified. The solution allows customization of questionnaires, scalable document storage, secured access to system, ad-hoc querying and reporting capability.MetricStream Solution has the ability to track regula-tory changes and follow them up with an appropriateaction plan. 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 maintainedMetricStream Solution has the ability to ensure com- with appropriate metadata for each questionnaire. Confidentiality setting can be configured to hide thepliance with a spectrum of regulations such as NAIC associate details.MAR, HIPAA/HITECH, and other CMS regulations.MetricStream Solution offers ease of use, security The system supports attaching and storing related records such as mitigation plans, reports,and scalability of application across enterprise. evidence, attestations and samples. The solution supports data retention for all survey records for a specified period as well as data archiving.MetricStream Solution provides flexibility to be con-figured to specific requirements with minimum need MetricStream GRC Platformfor programming. 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 restric- tive 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.For more information, visitwww.metricstream.comCopyright 2011. All Rights Reserved.