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Kofax brings streamlined processing of millions of Affordable Care Act insurance applications for The Centers for Medicare & Medicaid Services. The dynamic case management system ensures visibility and control throughout the entire onboarding process while delivering reduced costs and increased accuracy of data.

The Challenge

In accordance with the Patient Protection and Affordable Care Act (PPACA), the Centers for Medicare & Medicaid Services established a National Health Insurance Marketplace to facilitate access to affordable health insurance. Signed into law in March of 2010, the ACA was enacted to reduce the population of uninsured by expanding public and private insurance coverage.

As part of the law, each state was to establish its own state-based exchange. If a state elected not to create an exchange or was unable to do so, the law directed HHS to establish a federally facilitated exchange in each state and/or territory. While 17 states and the District of Columbia have established individual state insurance exchanges in accordance with the ACA, the remaining 33 states and territories rely on the federal government to manage efforts related to enrolling uninsured citizens as mandated by the ACA.

Enrolling citizens in the coverage requires collecting and managing millions of paper-based health insurance applications and supporting documents (as well as eligibility appeals, correspondence and redeterminations). These documents must be scanned and captured, reviewed, verified and distributed for processing to determine eligibility.

The Solution

The agency turned to Kofax to help automate and manage the information-intensive process of enrolling uninsured citizens in insurance exchanges; the goal was streamlining the process for quicker access to coverage and better service.

The comprehensive case management solution that manages the overall application process uses Kofax Capture™ to extract data from scanned application forms and trailing documents. In addition, Kofax VRS Elite™ cleans up poor quality images to ensure that image quality is adequate and information is accurately extracted from the paperwork.

The solution helps accelerate the information-intensive application process from receipt through approval by automatically digitizing and classifying the applications. It also helps collect supporting documents that may be requested after-the-fact and need to be matched with the original application to complete processing. Then, whether the documents received are on paper or in electronic format, Kofax Transformation™ can automatically extract and validate the appropriate information to verify the applicant’s status.

By automating and streamlining what would otherwise be manual, error-prone and time-consuming data entry, the Kofax solution reduces labor costs, eliminates errors and saves taxpayer money. It also eliminates expensive document sorting and filing to increase productivity and the volume of information that can be accurately collected and managed. This results in a streamlined application process.

To ensure the solution’s maximum up-time, Kofax Monitor™ provides real-time performance measurement, including service-level metrics, historical performance data and real-time processing status. It monitors the hardware infrastructure and notifies operators prior to a potential incident occurring, which allows preventive actions to be taken. This minimizes downtime and also keeps staffing and operating costs in check.

All paper-based applications and supporting documents are mailed to the processing center. Once received, employees scan the handwritten forms into the Capture and Transformation Modules system, review them for completeness, validate the data, export them into the comprehensive case management solution, process requests for appeals and notify consumers of any problems with their applications. After data is captured, the system automatically distributes relevant documents to processing centers.

The Kofax solution ensures compliance with established government protocols; including data governance, audit trail and eligibility rules, triggering alerts to applicants for missing information, pausing processing while awaiting supporting documentation and notifying constituents of eligibility. Through an eligibility support tool, operators can electronically monitor and search for paper applications that have not been processed due to validation errors or existing applications that are awaiting verification documents.

Customized views in the solution help operators manage and expedite processing while enabling them to update or correct missing or invalid information. Operators can contact the applicant electronically or by mail to request missing information or any necessary supporting documentation. After missing information is received, operators are notified to go back into the system and complete the consumer’s application. Additionally, there are processes for handling expedited applications.

The Results

With Kofax, the Federal Health Insurance Exchange has established a much more efficient and streamlined case management process in which all applications and supporting documentation are automatically scanned, classified and indexed on arrival. This enables operators to maintain visibility and control throughout the entire onboarding process. With the ability to monitor the status of all applications and their supporting documentation, the agency can enroll constituents more quickly and allows faster access to healthcare coverage, all while saving time, increasing accuracy and reducing labor expenses.

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