An integrated technology solution can help manage – and prevent disruption to – the pivotal enrollment, reconciliation and revenue process challenges posed by the new HIX marketplace.

The centerpiece of the Affordable Care Act, the health insurance marketplace brings vast potential. But it is also untried and untested. With U.S. healthcare still tentatively embracing automation, the marketplace presents a record number of systems that must somehow synchronize within tightly compressed timelines. Instead of careful implementation, insurers face rapid integration; they must balance caution with the prospect of 30 million enrollees and $200 billion in revenues within a decade.

Risky business

No amount of vigilance can eliminate every risk in this uncertain climate. CMS and the states issue changes frequently. Reporting requirements are complex. Scant IT resources and personnel already stagger under the weight of numerous and conflicting priorities.

These are compelling factors, but they shouldn’t be construed as the case against participation in the marketplace. Instead, they argue for the development of a proactive strategy, one aimed at blunting business impacts and laying a careful foundation. That entails a health insurance exchange (HIX) solution and related processes that are inherently flexible. They build capabilities that add value no matter where the future leads.

Ready, set, go

Processes, functionality and technology solutions contribute to the successful launch of an HIX business. Steeled by experiences with such behemoth initiatives as HIPAA 5010 and ICD-10, many insurers have already learned the importance of the first – process – and routinely enlist cross-functional teams to identify, plan and execute change.

But if history offers guidance around process, no precedent exists for the management of millions of new members and businesses and exposure of the insurer’s systems to myriad unknown entities. Insurers may find themselves working with more than one exchange, each reflecting different levels of volatility, progress and maturity. The familiar past model of extract, transform and load won’t sustain tomorrow’s premium stabilization solution. From an IT perspective, disruption seems not only possible but probable.

Ideal technology solution

A strong technology solution buffers the dynamic aspects of marketplace participation. First, it shields and monitors interactions between HIXs, financial institutions and the federal government. It ensures that only accurate and timely information is sent to core membership systems or reported. (Frequency of possible eligibility changes and ongoing payment cycles requires automation for identifying discrepancies and payment analysis.) It assists in the management of enrollment and transaction processing, as well as reconciliation and revenue; this centralization makes possible resolving discrepancies between payer and marketplace and must be viewed as mission critical. Finally, the solution provides insights on business performance.

After the launch … into the future

The health insurance marketplace represents an ocean of opportunity for insurers, but the waters are uncharted. To produce meaningful results from its HIX participation, insurers can employ a technology solution that accomplishes integration, depth, visibility and flexibility.

While the process of preparing to participate in the marketplace may be unprecedented, its goals – reducing healthcare costs and increasing its quality – are longstanding. The prescient insurer will use this opportunity to solidify technology, unify systems and consolidate efforts toward a universe of safely shared administrative and clinical data.

About the author

John Kelly is nationally recognized for his expertise in health information exchange. The principal business adviser at Edifecs, Kelly provides thought leadership and strategic consulting to the company’s numerous healthcare customers. Learn more about Edifecs at

HIX: Seizing opportunities while stemming operational impacts
By: HMT Mag
The Source for Healthcare Information Systems Solutions