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February 2013

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Get Ready to Navigate the Affordable Care Act

As important milestones approach for the implementation of the US Patient Protection and Affordable Care Act, the technology implications for healthcare payers are becoming clearer. Most significantly, the Act’s individual mandate, which guarantees access to health insurance for every American, will require payers to run flexible IT infrastructures that address a range of important customer-facing and backend business operations.

To help payers navigate these changes, Oracle published “Executing on the Individual Mandate: Opportunities and Challenges for Healthcare Payers,” a white paper that outlines the new technology requirements created by the Affordable Care Act and provides advice to help healthcare organizations make necessary changes to their existing IT environments.

Focus on Seven Areas
According to the white paper, payers will need to evaluate their IT systems across seven key operational areas.

  • Enrollment. Payers will offer individuals online enrollment options, whether through exchanges or their own Web portals. The underlying applications needed to provide this service include CRM, rating and underwriting, membership databases, and a document issuance systems.
  • Pricing. With online distribution and enrollment come new demands for more-competitive pricing. Pricing applications will be required to handle these new models.
  • Enterprise data management for individual members and groups. An expanding membership base will necessitate enterprise-level data management that can scale as membership grows.
  • Billing, payment, subsidy, and reconciliation. Payers will need systems that can handle individual, group, and split billing, where members are covered in part by Medicaid.
  • Customer servicing. This includes Web, mobile, tablet, social media, and kiosk channels, in addition to the traditional call center. Customer experience management software can help ensure consistent member experience across all channels.
  • Alternative reimbursement. Rather than the traditional “fee for service” model, states may mandate capitated services, where providers are compensated over a given period of time. Payers will face a growing need for standard applications that automate this process.
  • An integration strategy. Payers will need solutions that tie their systems into state and federal exchanges.

Oracle provides flexible solutions that address the requirements of healthcare reform. To learn more, read the white paper and visit Oracle’s Insurance overview resource center.

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