Tuesday, March 25, 2014

3rd Reason Why Health Insurance Exchanges Will Continue Floundering in 2014

In two previous posts I offered a 1st reason and 2nd reason why I thought the deployment of Federally-facilitated Marketplace (FFM) and many state run exchanges would continue to flounder in 2014.

Now that we are near the end of the first open enrollment period for “Obamacare” I’m going to outline the 3rd and final reason why I believe health insurance exchanges (HIX) will continue floundering into 2014 and likely beyond.

Those Stinkin’ Changes Have Messed Up My Eligibility and Billing!

Now that millions of people have enrolled, all subsequent transactions will be change transactions; or “corrections.” And there’s a difference between corrections and changes. I’d venture to guess that the majority of new enrolees are just getting to know where they stand in terms of member cards, eligibility at the doctor’s office and what they must pay every month in terms of premiums. And any errors are being discovered. Moreover, a certain percentage of people will drop out, stop paying their premium and will need to be cancelled. People will get married, divorced, have kids, age out of commercial plans and into Medicare, etc., etc.

But the FFM and many state exchanges have struggled and continue to struggle with exchanging enrolment transactions with Qualified Health Plans (QHP’s.)  Even plain, old vanilla “834 add transactions” have created heartburn. Anyone who’s spent any amount of time in IT should clearly understand that adding something to a system is usually quite simple to accomplish; but changing something that already exists is often problematic. Ans processing retroactive additions and changes present an especially challenging demand. The architecture of the FFM, where the FFM is considered the system of record but the QHP systems where the actual meat and potatoes of enrollment and eligibility processing are completed, demands precise, consistent and timely exchange of data. I don’t believe this is happening on a consistent enough basis.

Follow-On Effects of Corrections and Changes

So the downstream impact caused by faulty or improper corrections and change transactions is the 3rd reason why exchanges will continue to flounder in 2014. Billing and member eligibility can easily get screwed up creating additional administrative impact to providers and QHP’s. For the remainder of 2014 and throughout the 2015 open enrollment period, expect to hear about – and perhaps witness first hand if you purchased coverage via an exchange – just how solid and accurate enrollment corrections and changes are being originated by the FFM and state exchanges.

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