The ACA and Legal Practices (#10) / Dealing with enrollment data problems

August 20, 2014

health-care-lawThis is installment #10 in a series of blog postings on the Affordable Care Act (ACA) and legal practices.

More people are having problems dealing with ACA enrollment.

Solving these problems often requires looking at the full “data flow” that is taking place, and targeting fix-up efforts toward a mix of processing issues.

Enrollment involves information provided to the Health Benefit Exchanges by individuals; the processing of information by the Exchanges, with linkages to the Internal Revenue Service (IRS) and other federal agencies; data transfers to insurance companies and state Medicaid agencies; and information then transferred to providers.

This “forward” information flow is combined with “looping flows” from the Exchanges back to individuals, from insurance companies back to Exchanges and individuals, and from providers back to Exchanges, individuals, and insurance companies.

Also included in the data flow mix are “navigators” (who provide in-person help) and telephone call centers (which provide remote call-in assistance).

However, there is no central “data controller” to make sure that all of these linkages work as intended. Each linkage is to be developed and maintained by the organizations involved.

Unsurprisingly, as a result, many data flow problems have developed and these problems are often difficult to fix.

Individuals have to cope with possible errors through data entry by themselves (often due to the complexity of forms); navigator errors; and call center errors in the information being entered.

Any mistakes through these pathways can run through all organizations.

The Exchanges have to worry about internal processing errors, transfers to and from other federal agencies, and information sent to insurance companies and state Medicaid programs. Any mistakes throughout this flow will prevent enrollment from being successfully completed.

Significant problems are also being encountered with efforts by individuals to fix past errors and to update their enrollment information when changes occur in their lives. Levels of processing activity by the Exchanges are continuing to be high due to these factors.

Further, new enrollment and reenrollment procedures will go into effect on November 15, for Year 2.

Delays and errors in initial enrollment, updates and revisions, and reenrollments can result from systematic software coding problems, organizational interface problems, and data entry errors.

Data transfers to insurance companies and Medicaid agencies can introduce new errors, as can transfers to providers.

Finding and fixing data flow errors can be a difficult task. In many situations, individuals may turn to attorneys for assistance.

In some situations, attorneys may have to work the “whole problem”, tracking data flow through the entire system, from organization to organization, in an effort to locate the reasons for problems. Substantial effort may be required to gain the needed attention and access to resolve such problems.

And more fixes may be required as rules change, enrollment input changes, reenrollment ramps up, and provider requirements evolve.

More information about the Health Care Exchanges and the ACA may be found in recent books on the ACA and on the health care system, other postings to this blog, and on the ACA Blog, also written by the author of this series.