Unified Payment Review System
Background
The Exchange Improper Payments Measurement (EIPM) Program was established to reduce fraud and abuse in the Federal Health Benefit Exchanges accessed through Health.Gov. EIPM determines the annual amount of improper payments issued by the federal health agency under the Advance Premium Tax Credit (APTC) program, administered by the Federally Facilitated Exchange (FFE). The program demands a rigorous, data-intensive series of measurement activities: auditors collect data across more than 16,000 parameters and sample more than 2,000 aid applications each year for a detailed review of APTC eligibility, payments made, and compliance with other program policies. For every application, auditors assess improper payments, report findings, and support dispute resolution and appeals in response to complaints from impacted parties.
Our Role
Ignyte Group delivered an Appian-based software platform that transformed the audit process and strengthened risk management and quality assurance across the application review process. The solution also included a dedicated EIPM Policy Management module, giving auditors the ability to tie review findings directly to applicable policies.
Ignyte Group partnered with the federal health agency to define technical and functional requirements for the Appian-based EIPM solution, then configured and tested the platform to meet them. Ignyte Group engaged stakeholders across the organization — including the contracted audit team and other federal agency partners — to ensure the system met every user’s needs.
Ignyte Group helped design and implement integrations with other agency systems required to ingest the data needed for the audits and supported the assigned federal health agency Security Officer to achieve an Authority to Operate (ATO) by guiding key decisions around the security architecture and providing documentation of the system design and security configuration on the Appian process automation platform.
Ignyte Group designed a system built to expand and adapt as scope or legislation changes over time. As part of this effort, the solution incorporates Investigative Case Management (ICM) capabilities, giving auditors efficient tools to track, analyze, and resolve complex cases. Ignyte Group also established clear maintenance and operations procedures and mentored agency staff to support and sustain the Appian EIPM solution long after go-live.
Measurable Outcomes & Impact
The following are the key accomplishments and impact of our team’s solution and delivery:
- Delivered solution to track and manage real-time status of over 2,200 applications.
- Digitized the collection of over 1,600 parameters per audit, resulting in data collection of over 3.5M records.
- Delivered a real-time dashboard of application status, review progress, key findings, disputes, and appeals.
- Built a digital repository of over 80 EIPM Program Policies.
- Each policy module includes up to 50 individual policy lines.
- Established governed policy workflows to track and approve every policy change.
- Deployed an auditable digital record system to track and manage over 200 stakeholder disputes and appeals annually, with automated real-time alerts to reviewers.
- Provisioned system access for more than 50 users.
- Built a configurable architecture designed to adapt quickly to evolving regulatory requirements.
- Delivered knowledge transfer and mentoring to agency staff to support and maintain the Appian solution long-term.
