Mired deep in early problems it didn't expect with the exchanges, Aetna turned to tools from its previous large enrollment experiences to get operations on track.
Aetna's approach has been to handle their federal and state-based exchanges' relationship as any large customer sending electronic enrollment, including using standardized file formats – commonly referred to as 834s – for customer information and doing monthly reconciliation.
"It all felt very familiar to us," said Jane Good, program director of service operations technology solutions at Aetna.
Before Oct. 1, Aetna focused on slight variations in this model, such as the consumer shopping on the marketplace and getting a confirmation of their premium there. "We wanted to be sure that one of the first member-facing documents that members get from Aetna--the invoice – would match what the consumer saw on the exchange," she said.
So the insurer built tools comparing the financial amounts on the 834s with Aetna's calculated financial amounts, with a daily report and emailed alarms when there were mismatches. "This proactive approach to one of our worries proved useful when we started seeing these differences," she said at the recent exchange conference sponsored by America's Health Insurance Plans (AHIP).
Aetna also assembled a command center SWAT team of technology and operational experts, who met every morning to get a leg up on any problems on Healthcare.gov and state exchanges.
"Some situations that we thought might be an exception to the scenario, like multiple transactions by the same member on the same day on Healthcare.gov, turned out to be more the standard," Good noted. The lack of codified 834s in those early days made processing those multiple transactions a challenge. And some of the companion guides explaining the state exchange operating processes were inaccurate.
"We could put tactical solutions in place and advocate with the various exchanges for a better solution or scramble and make coding changes," she said, adding that Aetna had established some processes to assure that all members' data sent by each of the exchanges entered its systems as quickly as possible.
Aetna recommended that the major carriers, the alpha group, see a file extract of all the active members believed to be enrolled in the CMS database to make sure they were all synched up.
"That was the seed that turned into the discovery of what we now call orphan records, enrollment completed on Healthcare.gov that never got sent to the carrier for various reasons," Good said. From that discovery, they created plans to address the gap.
In early December, all issuers received this pre-audit file from CMS so they could tackle the orphan records and any other data disconnects.
The early first weeks of lower-than-expected membership volumes were like a pilot and offered an opportunity to more carefully analyze the data and trends. It enabled the team to put in some quick changes and handle unexpected data scenarios.
"When enrollment picked up in late November, we were ready. It seems that somewhat obsessive data analysis on our part also prepared us for the recently announced payment work around," Good said. "We've been so much in weeds on every bit of this data, we were able to fairly quickly assemble a solution for the financial template that CMS is using for January payment."
"Despite the sound and fury, there have been some successes. We all are focused on the exact same goal – getting membership enrolled in the right plans and getting every member the information they need to access their benefits online."
The hard fought experiences brought a silver lining of significant collaboration among major payers in an alpha group, along with the CMS team for Healthcare.gov and state-based marketplaces, and others brought in, like Optum, for "unraveling complex issues and noodling creative solutions," she said, which should put them in a better position for whatever comes in 2014.
By mid-year, Good anticipates not having any manual processing as the 834 process gains more confidence.
"It feels like we have enough of that foundational flow solid that we're comfortable enough to start to shift toward the service end of it. We've got our stride now," Good said.