Abstract

The healthcare industry is in the midst of constant change and reform. One of the largest healthcare organizations called on SDLC Partners to help manage the healthcare reform bill in order to maximize valuable reimbursements for its clients.

The Challenge

In response to the 2010 Health Care Reform Bill, one of the country’s largest healthcare organizations was required to adhere to the new Government Health Care Program and changes for the Early Retiree Reinsurance Program (ERRP). EERP provides reimbursement to participating employment-based plans for a portion of the costs of health benefits for early retirees and early retirees’ spouses, surviving spouses, and dependents. The program was authorized in the Affordable Care Act.

Changes to the Health Care Reform Bill and subsequent implementation phases were not clear, which resulted in numerous challenges for the client, including:

  • Meeting tight deadlines
  • Adhering to Government Health Care Program’s ongoing changes
  • Managing risk
  • Responding to client inquiries
  • Maintaining clarity over reimbursements
  • Understanding request logistics of tracking status

The Solution

SDLC Partners assisted the client by closely monitoring and managing the ongoing compliance project. The SDLC team closed information gaps by attending external healthcare information sessions and seminars. Using the information and following the project plan, the team was able to make informed decisions, which substantially reduced the risk in this changing and somewhat confusing new healthcare environment. SDLC developed a quality infrastructure to handle the rapid and often unclear changes. SAS was used to aggregate member and claim data, filtering the data by age and threshold dollars. To increase productivity, the request status was automated and maintained using control tables. This significantly reduced program errors and response time. The disbursement is provided on a first to submit, first to receive basis, which made timely submission a critical task. The newly established infrastructure enabled SDLC to submit reimbursement requests for the client and to receive the maximum value.

The Results

With SDLC’s assistance, the client fully understands the new program and is viewed as one of the most knowledgeable leaders for this program. The department gained respect and recognition from internal client managers and division heads. This client was able to make informed decisions before other insurers even knew the answers, which enabled the client to be awarded 28% of the available reimbursement for the Pennsylvania and Maryland region.

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