Overview:

Process Redesign and Technology Enablement for SBC compliance in a Large, East Coast Healthcare Payer

Business Issue:

This Large, East Coast Healthcare Payer needed to meet the requirements of the Affordable Care Act (ACA) regulatory requirements, for the timely and accurate production and delivery of Summary of Benefits & Coverage (SBC) documents. This organization wanted to avoid being subject to penalties, while maintaining compliance when preparing, delivering, and storing SBCs.

Actions:

• Prepared regulatory overview of the SBC delivery requirements applicable to the Payer’s lines of business
• Analyzed and recommended the technology platform to be used to generate SBCs
• Developed and implemented new processes to support the generation of SBCs using the technology tools
• Facilitated decisions on how to display standard and non-standard plan information in the SBC
• Created SBC quality assurance documents for training and roll-out of the new process and technology
• Conducted training across all departments on how to complete and then store an SBC
• Managed SWAT SBC Production teams to generate and store SBCs
• Performed overall program Management to ensure successful initiatives

Results:

• Completed all required SBCs before year-end for 1/1 renewals and new business
• Implemented an automated solution for generating SBCs to increase throughput and improve quality
• Documented the completion of each SBC, allowing the Payer to validate and communicate compliance to regulatory agencies
• Enhanced the Payer’s SBC standard process through the development of two additional support efforts:
• Ability to convert and translate the SBC into select foreign languages
• Ability to manage inquiries and feedback from the Payer groups, consultants, and other customers
• Improved the speed to generate SBCs over 3 months by 50%
• Improved the accuracy and completeness of generating SBCs by 66%