Health Insurance Exchanges Bring Concerns of IT Disruptions: Survey

Insurers want to implement federally mandated health insurance exchanges, but they worry about IT infrastructure headaches, an Edifecs survey revealed.

Health insurers are embracing the move toward health insurance exchanges, yet they're concerned about IT infrastructure changes, according to a Feb. 20 report by Edifecs, a health care IT software company.

The Obama administration's Affordable Care Act calls for states to implement the exchanges, referred to as HIXes, by October 2013 or have the federal government implement them on their behalf. The Web-based exchanges allow small businesses or uninsured individuals to purchase health insurance.

Edifecs—which based its study on interviews with 125 senior health care professionals at the 2013 Healthcare Mandate Summit Feb. 4 to 6 in Austin, Texas—found that 95 percent of respondents plan to participate in an HIX, and 80 percent will join in 2014.

However, 88 percent of respondents are concerned about disruptions to their current IT enrollment infrastructure and processes when they join an exchange. Insurers will have to create new business processes and integration points rather than simply add new data from individuals and small businesses, according to Jamie Gier, vice president of corporate marketing at Edifecs.

"It goes beyond simple data feeds," Gier told eWEEK in an email. "Beyond integrating their systems with federal and/or state exchanges, insurers will need to reconcile their detailed member records with those maintained by the exchange on at least a monthly basis."

Insurers must manage and reconcile their membership records between their own insurer systems and HIXes, said Gier. This cross-checking of data will confirm eligibility and credit premiums, as well as ensure correct payments, said Gier.

In the survey, insurers also voiced concerns about a lack of time for sufficient testing of the exchange systems, said Gier.

"We are now less than eight months from the Oct. 1, 2013, deadline for exchanges to start offering enrollment," Gier noted. "Many systems have yet to be set up, and all must be tested across multiple scenarios."

A lack of comprehensive testing of IT systems could lead to major disruptions for the carriers and the exchanges. In fact, HIX health plans go into effect Jan. 1, 2014, and qualified health plans, benefit tiers and payment contracts must be entered and integrated with insurers' IT systems by then, said Gier.

Many states will also have to overhaul their existing IT systems to comply with the Affordable Care Act, the survey revealed.

Ninety-three percent of respondents said they wanted more input in how the exchanges will be built. In addition, 69 percent said the information received from exchanges to date was either "poor" or "very poor."
A lack of common data interoperability could be a problem as insurers transmit and receive information in the exchanges, Gier suggested.

Of respondents, 39.7 percent were "somewhat concerned" and 35.3 percent were "very concerned" about being able to support multiple formats from different exchanges. In addition, 96 percent of respondents were concerned about data formats changing over time.

"These formats will likely change as each exchange fixes issues and improves business processes," said Gier. "Insurers will need flexible IT systems to accommodate the changes."

Insurers participating in more than one exchange face additional data-transfer challenges. More than 30 percent of survey respondents intend to participate in three to five exchanges, according to Gier.

Meanwhile, doctors could face payment delays if insurance exchange data doesn't match up.

"In the HIX model, that goal is more difficult to achieve because insurers have to work with the exchange and the federal government to reconcile and verify information," Gier noted.

Still, the Web-based exchanges will bring fewer unpaid bills for doctors, said Gier.

She noted that low or unpredictable data quality will also be a challenge in HIXes.

"Health plans will need to carefully examine membership/enrollment updates coming from state exchanges," said Gier. "Each state is at varying stages of HIX adoption and will have their own transaction formats, member identifiers and process flows."