Where is the Healthcare Industry Going Next? · 2016. 3. 9. · Trizetto . FACETS . QNXT . New York...

Where is the Healthcare Industry Going Next?

Healthcare Technology & Business Trends

Company : Solution

Federal & State Based Marketplace (HIX) Integration

Premium Billing

Private Exchanges

Direct Enrollment

Edge Server/CSR

Reconciliation

Softheon: Marketplaces

HealthEdge

ikaSystems

DST

Trizetto FACETS

QNXT

New York

California Massachusetts

Washington

Arkansas

Indiana

FFM

EPIC

Interstate Highway of Exchanges Carriers can drive their cars and trucks on Softheon, rather than

building their own roads to Public and Private Exchange destinations

Value: Health Insurance

Centene

MDwise

FirstCare of Texas

Paramount Health

Community Health Choice

IU Health

Community Care of Oklahoma

Total Health Care of Michigan

Florida Health Care Plans

Community First Health Plan

Health Republic Insurance

Affinity Health Plan

Group Health Cooperative

New York

Arkansas

FFM

Indiana

Massachusetts Washington California

Towers Watson

GoHealth

AON Hewitt

Metrics: Exchange Enrollments

Enrolled over 700,000 in 2015, and grown to nearly 1,600,000 in 2016

Metrics: Billing & Payments

Processed over $350,000,000 Insurance premiums in 2015, projected to grow to $600,000,000 in 2016

Market: Payment Transaction Confirmed Minus Fee Funds Deposited to Carrier

Transaction Authorized And Reconciled Against

Billing

Consumer Pay Insurance Premium by Credit & Debit Card, ACH, and Check

Consumer

Value: Health Insurance: Softheon

Metrics: Administrative Loss Ratio

Value: Health Insurance: Softheon

Build 24 FTEs 180 Days

Plug In 4 FTEs 30 Days

Value: Edge Server and PCM Technology At Softheon, we are leveraging our proven Edge Server technology for data submission.

Edge Server

We have configured our Edge Server platform for CSR to: • Aggregate Professional, Institutional,

Pharmacy, and Supplemental Data • Accommodate disparate Enrollment

Data to validate: • Member Coverage Period • Monthly Premium Amount • QHP Plan ID

• Provide Plan Catalog Management

Data Analytics: Claims Analysis

Value: Health Insurance: Profit & Loss

Data Analytics: P & L Analysis

Value: Health Insurance: Analytics

Value: Health Insurance: Actuarial

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