Health insurance compliance


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Case Study - One of the world's largest health insurance companies chooses MetricStream solutions to strengthen its safety and compliance.

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Health insurance compliance

  1. 1. CASE STUDYMetricStream A Leading Health Insurance Provider Strengthens Compliance Management Customer The Company is one of the world’s leading health insurance providers and offers a broad range of medical and specialty products. 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 inte- grated health care plans and related services, along with a wide range of specialty products such asCustomer life and disability insurance benefits, pharmacy benefit management.ONE OF THE WORLD’S LARGEST HEALTHINSURANCE COMPANIES 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 responsibil-Benefits ity towards its stakeholders.Streamlined compliance: With automated workflow As an aftermath of the overhaul that the US healthcare system is undergoing, several health insuranceand meticulous data tracking, the Company has providers are reinforcing their Governance, Risk and Compliance (GRC) programs to manage their risksstreamlined its compliance to applicable regulations better, gain enterprise-wide vision and ensure complete compliance with multiple regulatory require-significantly. Centralized structure of the overall ments and corporate policies. A number of health plans, recently responded to the rapidly changingregulatory alerts and executive dashboards provide regulatory environment by redefining their compliance strategies and redesigning the processes,real-time information on the compliance process, systems and tools being used to support compliance programs.enabling the Company’s regulatory group to ensurecompliance with regulatory and safety requirements. ChallengeProactive regulatory tracking and effectivemanagement of regulatory actions: Integration of a Growing regulatory demands: With major changes been made to health insurance law in the Unitedhuge volume of relevant regulations in the applica- Sates, the regulatory demands for health insurers have been constantly increasing, resulting in antion workflow has enabled the Company to track extremely intricate web of regulations at various levels - national, regional and state, data and infor-every regulation and related actions proactively. This mation management , market segments and product offerings to mention a few.contrasts with the previous situation at the Companywhere regulatory tracking was more reactive anddependent on emails and personal communication. As the pressure to comply with this complex maze of regulations began mounting, the CompanyMetricStream solution has minimized the instances required a sound program for managing and sustaining regulatory compliance, preventing fraudof overlooking regulatory changes or failing to act and abuse and managing incidents of non-compliance, among others. For instance, a major area ofupon them. 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,Improved decision-making capabilities: With advertising materials, marketing, policyholder services, underwriting, rating, claims handling prac-MetricStream’s powerful analytics and business intel- tices. The formats and procedures of resulting corrective action plans also differ widely from state toligence provided by the built-in reporting engine and state and pose a challenge in standardizing operations.role-based dashboards the Company can proactivelytrack all metrics and indices to resolve issues and Stronger responsibility: With changes in the US health care system giving rise to strong account-take decisions based on facts and data. ability towards policyholders, shareholders and employees, consumer empowerment and protectionStronger control on fraudulent activities: Equipped featured as a mandatory part of best practices and market conduct examination reports and conflictwith automated alerts, source capturing, trend of interest surveys acquired greater importance requiring rigorous planning , elaborate informationanalysis and dollar value tracking the Company is collection and detailed data analysis and to control the fraud and abuse incidents moreeffectively. 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 aEnhanced public image: MetricStream’s reportingand status tracking capabilities mapped to regulator result, the Company faced challenges in achieving effective management of information routing taskaudits through various stages have led to public for critical areas such as accreditation, documentation, fraud, abuse, incidents of non-compliance, andmarket conduct examination reports that speak for conflict of interest surveys.themselves. This has helped enhance the Company’spublic image greatly in the eyes of its stakeholders Need to improve fraud and abuse claims management: The risk of fraud and abuse violation hasand has minimized the risk of severe corrective action increased for companies that provide benefits to Medicare and Medicaid recipients. Governmentplans, sanctions and fines. 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 signifi- cant importance for the Company.
  2. 2. MetricStream 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 solu- tion 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 report- ing 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. “MetricStream has mapped its solution to support our specific needs and workflow struc- ture. 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. 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 success- ful 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 regula- tor. 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
  3. 3. execute certifications based on predefined templates and schedules for designated executives. Theresult of the follow-up task is routed back to the appropriate executives for approval and final closureof the case.Conflict of interest surveys: MetricStream has integrated its application with PeopleSoft ERP systemin order to facilitate extracting and synchronizing associate data and organizational data of the Com-pany 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 resolvingany conflicts of interest that are identified. The solution allows customization of questionnaires, scal-able 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 maintainedwith appropriate metadata for each questionnaire. Confidentiality setting can be configured to hide theassociate 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 aspecified period as well as data archiving.Accreditation: The accreditation process to distinguish health plans based on scored quality metricsrequires the Company 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 otherdocuments 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 organizedand grouped in a logical fashion with the ability to create any number of sub-categories and tree-likehierarchies.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-assessmentsbased 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.Document management: MetricStream’s solution enabled integration with content feeds to recognizechanges 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 ofusers including external auditors and third parties with real-time read-only access to certain documen-tation.The application supports check-out and check-in of documents to ensure version control. At eachstage of the document, multiple authorized users can access the document simultaneously andcomplete their respective tasks. All the information is merged and can be viewed in completion or byfiltering based on the reviewer.To protect the security of the documentation, the access is controlled. In addition, MetricStreamplatform records all access and modifications within the system, including user and system data. Anyrecords, 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 ap-propriate views. The entire access and edit history of a record is captured with accurate time-stamps.
  4. 4. Fraud and abuse/incident management: MetricStream solution provides the Company an enterprise-Why MetricStream wide visibility into incidents, ability to distinguish case types, automated workflows to remedy inci- dents, and regulatory reporting. It allows tracking of fraud and abuse claims by special investigationMetricStream solution is workflow-based and has units (SIUs) and departments from initiation to closure.versatile reporting capabilities with every piece oftracked data being a reportable field and ability to cre- The source of the case and dollar values associated with it are captured and tracked for reporting andate customized reports and templates to match the trend analysis. Graphical executive dashboards and flexible reports with drill-down capability provideCompany’s frequently changing reporting needs. statistics and data based on parameters such as by SIU, department, incident type, sub-type, busi- ness units, functional processes and locations.MetricStream solution supports several layers ofdownstream assignments that can be managed in-dependently with a capability to roll information back At the time of initiation, the system captures detailed information about the case and supports catego-upstream for wider reporting requirements. rization 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 depart-MetricStream solution integrates regulatory infor- ment for investigation and response. Different workflows are set up for different case types. Notifica-mation with the application workflow, facilitating tions are sent to relevant departments and personnel. Status reports as well as automated alerts allowfoolproof regulatory alert tracking and management. the teams to keep track of updates and changes to cases.Along with ease of use and secure database, Metric-Stream solution also offers data tracking in multipleformats.MetricStream has the ability to support largeorganizations and meet their varying compliancerequirements as well as IT requirements in the areasof integration, configurability, scalability and security.For more information, visitwww.metricstream.comCopyright 2011. All Rights Reserved.