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 solution 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 reporting 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.
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 successful 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
Monday, May 20, 2013
Growing regulatory demands
With major changes been made to health insurance law in the United Sates, the regulatory demands for health insurers have been constantly increasing, resulting in an extremely intricate web of regulations at various levels - national, regional and state, data and information management , market segments and product offerings to mention a few.
As the pressure to comply with this complex maze of regulations began mounting, the Company required a sound program for managing and sustaining regulatory compliance, preventing fraud and abuse and managing incidents of non-compliance, among others. For instance, a major area of 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, advertising materials, marketing, policyholder services, underwriting, rating, claims handling practices. The formats and procedures of resulting corrective action plans also differ widely from state to state and pose a challenge in standardizing operations
Stronger responsibility: With changes in the US health care system giving rise to strong accountability towards policyholders, shareholders and employees, consumer empowerment and protection featured as a mandatory part of best practices and market conduct examination reports and conflict of interest surveys acquired greater importance requiring rigorous planning , elaborate information collection and detailed data analysis and reporting.
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 a result, the Company faced challenges in achieving effective management of information routing task for critical areas such as accreditation, documentation, fraud, abuse, incidents of non-compliance, and conflict of interest surveys.
Need to improve fraud and abuse claims management: The risk of fraud and abuse violation has increased for companies that provide benefits to Medicare and Medicaid recipients. Government 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 significant importance for the Company
As the pressure to comply with this complex maze of regulations began mounting, the Company required a sound program for managing and sustaining regulatory compliance, preventing fraud and abuse and managing incidents of non-compliance, among others. For instance, a major area of 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, advertising materials, marketing, policyholder services, underwriting, rating, claims handling practices. The formats and procedures of resulting corrective action plans also differ widely from state to state and pose a challenge in standardizing operations
Stronger responsibility: With changes in the US health care system giving rise to strong accountability towards policyholders, shareholders and employees, consumer empowerment and protection featured as a mandatory part of best practices and market conduct examination reports and conflict of interest surveys acquired greater importance requiring rigorous planning , elaborate information collection and detailed data analysis and reporting.
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 a result, the Company faced challenges in achieving effective management of information routing task for critical areas such as accreditation, documentation, fraud, abuse, incidents of non-compliance, and conflict of interest surveys.
Need to improve fraud and abuse claims management: The risk of fraud and abuse violation has increased for companies that provide benefits to Medicare and Medicaid recipients. Government 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 significant importance for the Company
Benefits
Streamlined compliance: With automated workflow and meticulous data tracking, the Company has streamlined its compliance to applicable regulations significantly. Centralized structure of the overall regulatory alerts and executive dashboards provide real-time information on the compliance process, enabling the Company’s regulatory group to ensure compliance with regulatory and safety requirements.
Proactive regulatory tracking and effective management of regulatory actions:
huge volume of relevant regulations in the application workflow has enabled the Company to track every regulation and related actions proactively. This contrasts with the previous situation at the Company where regulatory tracking was more reactive and dependent on emails and personal communication. MetricStream solution has minimized the instances of overlooking regulatory changes or failing to act upon them.
Improved decision-making capabilities: With MetricStream’s powerful analytics and business intelligence provided by the built-in reporting engine and role-based dashboards the Company can proactively track all metrics and indices to resolve issues and take decisions based on facts and data
Improved decision-making capabilities: With MetricStream’s powerful analytics and business intelligence provided by the built-in reporting engine and role-based dashboards the Company can proactively track all metrics and indices to resolve issues and take decisions based on facts and data
Improved decision-making capabilities: With MetricStream’s powerful analytics and business intelligence provided by the built-in reporting engine and role-based dashboards the Company can proactively track all metrics and indices to resolve issues and take decisions based on facts and data
Improved decision-making capabilities: With MetricStream’s powerful analytics and business intelligence provided by the built-in reporting engine and role-based dashboards the Company can proactively track all metrics and indices to resolve issues and take decisions based on facts and data
Stronger control on fraudulent activities
with automated alerts, source capturing, trend analysis and dollar value tracking the Company is able to control the fraud and abuse incidents more effectively.
Stronger control on fraudulent activities: Equipped with automated alerts, source capturing, trend analysis and dollar value tracking the Company is able to control the fraud and abuse incidents more effectively
Enhanced public image: MetricStream’s reporting and status tracking capabilities mapped to regulator audits through various stages have led to public market conduct examination reports that speak for themselves. This has helped enhance the Company’s public image greatly in the eyes of its stakeholders and has minimized the risk of severe corrective action plans, sanctions and fines
Stronger control on fraudulent activities: Equipped with automated alerts, source capturing, trend analysis and dollar value tracking the Company is able to control the fraud and abuse incidents more effectively
Enhanced public image: MetricStream’s reporting and status tracking capabilities mapped to regulator audits through various stages have led to public market conduct examination reports that speak for themselves. This has helped enhance the Company’s public image greatly in the eyes of its stakeholders and has minimized the risk of severe corrective action plans, sanctions and fines
When to Explore Rates for Auto Insurance
How often do you think about your auto insurance rates? If you're like many, you
only consider your rates during renewals. If so, you may be surprised to learn that
auto insurance companies periodically raise insurance rates across the board.
Therefore, you might have taken the best deal for insurance when you first bought it,
but now, you could be paying more than necessary for your auto coverage.
That's why it's a good idea to check auto insurance rates at least yearly to ensure you
can't get equal or even better coverage for less than what you're now paying. Plus,
you may experience other situations that should trigger a re-checking of your rates
for auto insurance.
only consider your rates during renewals. If so, you may be surprised to learn that
auto insurance companies periodically raise insurance rates across the board.
Therefore, you might have taken the best deal for insurance when you first bought it,
but now, you could be paying more than necessary for your auto coverage.
That's why it's a good idea to check auto insurance rates at least yearly to ensure you
can't get equal or even better coverage for less than what you're now paying. Plus,
you may experience other situations that should trigger a re-checking of your rates
for auto insurance.
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