Overview

As part of the Affordable Care Act (ACA) and specifically the Medical Loss Ratio (MRL) program, CareFirst BlueCross BlueShield is mandated to provide patient rebates for any costs that do not meet the small or large group care allocations. These rebates need to be mail annually by law on a respective date so timing is critical to stay in ACA compliance.

A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. If an insurer uses 80 cents out of every premium dollar to pay its customers’ medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80%. A medical loss ratio of 80% indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs, and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws. Source: healthcare.gov

The Problem

CareFirst receives millions of claims per year that is processed and aggregated to calculate the total cost of care provided to patients. This data was then compared to the premiums received against multi-year averages and aggregated by multiple jurisdictions, legal entities, and sizes. By law, these numbers need to be exact and to the penny or subject to steep fines that can be $10,000/day/patient. Data quality is paramount to being in compliance with ACA.

The Solution

Using advanced data analytics, dashboards, and techniques, Agape worked with CareFirst actuaries to validate and confirm that claims stored in the MLR specific tactical data store matched gold sourced data to the penny. The data were also compared at several grains of data to ensure ACA compliance. That data was then aggregated using state of the art dashboards to present to executives for attestation signoff.