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