Multi-State Health Plan Traverses ACA Complexities to Meet Requirements, Reduce Risks

Whether you’re referencing the 381,517 words of the Affordable Care Act (ACA) or the nearly 12 million words (and counting) of “final” ACA regulations, the ACA is one of the most complex federal laws ever enacted.
Even with its decades of experience, a large, multi-state health plan needed external help to support its organizational readiness for implementing complex components of the ACA. The health plan engaged Freed Associates (Freed) to support cross-functional teams in multiple states, accomplish compliance readiness efforts, and develop a go-to-market plan for a changing line of business.

Goal

The Freed and client project team sought to ensure that the client’s ACA-related processes and systems included the business requirements contained in the ACA’s expanded definition of “small group” employers. During this internal changeover period, the client also wished to maintain its status as a trusted advisor to its small group clients. Thus, Freed and the client created and implemented a dual-track ACA update process to ensure that the client could both satisfy its internal operational readiness goals as well as continue to demonstrate externally its ACA expertise through a dedicated training component for customer-facing staff.

Strategy

Freed came to the client with a strong understanding of the small employer line of business, the regulatory climate affecting small employers, and the customers being served by the client. Freed joined a client team that had developed a core project plan but needed additional resources to execute on its readiness efforts and support its sales and retention strategy planning. Like many other health care organizations, the client already had a strong sense of its intended direction but needed Freed’s industry experience and expertise to get there.
Freed consultants and the client collaborated on creating and implementing a sequential, multi-faceted strategy that would enable the client to meet its needs for accomplishing internal technical/regulatory updates compliant with ACA regulations and demonstrating external ACA-related expertise.

Tactics

As part of the client’s core strategy, Freed consultants provided several value-added services including:

1. Project management leadership – Based on Freed’s strong experience with the ACA and overall regulatory environment, Freed consultants led internal compliance efforts, ensuring that the client did not overlook key details during implementation. Given the potential financial penalties for organizations that fail to comply with the detailed tenets of the ACA (despite its complexity), Freed’s knowledge and oversight in this area proved invaluable to the client. Freed also supported the development of a three-pronged client training program for account management staff (combining Freed and client resources).

2. Contingency planning expertise and structure – With a compliance-related project as complex as components of the ACA, it is critical to plan and implement contingency plans for when (not if) original plans go awry. Freed helped lead and implement contingency planning for the client, which proved useful as many of the client’s original ACA implementation plans encountered roadblocks. In the end, Freed and the client created a streamlined implementation process with contingencies included that kept the client from experiencing financial loss due to compliance-related delays.

3. Sales and marketing expertise – It’s one thing to know the technical components and details of the ACA; it’s another to be able to communicate them properly and effectively in sales and marketing channels to their intended audiences. Drawing from Freed’s health care sales and marketing experience, Freed consultants provided recommendations and direction to the client to help shape operational readiness efforts and rollout of communication materials. This resulted in improved communications within the client organization as well as to the client’s clients, resulting in measurable financial savings. Due to a lack of available client resources, Freed also functioned as the business application owner and national manager of an online sales tool for the client that needed to be updated based on ACA requirements.

4. Systems remediation – In combination with client resources, Freed guided the client’s critical systems remediation efforts, which included running requirements, designing sessions, writing software, testing systems, fixing bugs, and perhaps most importantly, serving as the vital link between the client’s administrative and IT functions.

Results

At the conclusion of Freed’s engagement with the client, the client was able to:

1. Remediate all internal and vendor systems used to support the sales cycle and membership administrative process

2. Execute a go-to-market plan with an ACA-compliant portfolio of products in each market served, as well as a tangible set of metrics to measure success

3. Conduct a three-phased training approach for both internal staff as well as prepare for training/consulting with customers on the requirements of the ACA and the recommended approaches needed to comply with the law

4. Prepare and track robust contingency plans for a number of possible scenarios that posed a risk to successful execution; ultimately for this engagement, Freed created dozens of contingency plans covering five different regions of the client’s operations

Conclusion

Based on its years of project management experience and depth of health plan expertise, Freed helped the client successfully navigate the uncharted and potentially hazardous depths of the ACA. Freed consultants provided the right combination of project management oversight as well as business, process and systems and development experience to ensure that the client was prepared, internally and externally, to fulfill the requirements of the ACA and communicate them accordingly to its clients.