Healthcare

Integrated Payment Review Solution

Background

The Exchange Improper Payments Measurement (EIPM) Program was established to reduce fraud and abuse associated with the Federal Health Benefit Exchanges accessed through Health.Gov. The EIPM is designed to determine the annual amount of improper payments made by the federal health agency related to the Advance Premium Tax Credit (APTC) program as administered by the Federally Facilitated Exchange (FFE). This program requires auditors to prepare for a rigorous series of measurement activities (including data collection of over 16,000 parameters). More than 2,000 aid applications are sampled per year, for a detailed review of ATPC eligibility, payments made, and compliance with other program policies. Auditors assess any improper payments for each application and report findings, as well as support follow-up questions in the dispute resolution and appeals process in response to complaints from impacted parties.

Our Role

Ignyte was tasked to deliver an Appian-based Software Platform to digitize the audit process and improve overall risk management and quality assurance / quality control procedures over the application review process.  This solution also included a module for EIPM Policy Management and the ability to tie review findings to applicable policies.

Ignyte supported the federal health agency to elicit and document technical and functional requirements, and ultimately configure and test the Appian-based EIPM Solution. To do this, Ignyte engaged a variety of users, including the contracted audit team as well as other relevant federal agency stakeholders that required access to the system and its outputs.

Ignyte 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 overall system design and specific security configuration on the low-code Appian Platform.

Ignyte designed a flexible and scalable system that can accommodate future expansion of scope or evolving requirements due to changing legislation. Ignyte also established clear maintenance and operations procedures and mentored agency staff on how to support and maintain the Appian EIPM solution.

Key Accomplishments & Impact

The following are the key accomplishments and impact of our team’s solution and delivery:

Key Accomplishment
Implemented Appian-based Solution to streamline the EIPM Application Assessment Process to identify compliance issues and improper payments
Business Impact
  • Delivered solution to track and manage real-time status of over 2,200 applications
  • Digitized the collection of over 1600 Parameters Per Audit (resulting in data collection of over 3.5 M records
  • Provided a real-time dashboard of application status, review overall progress, key findings, disputes, and appeals
Key Accomplishment
Established a digitized EIPM Policy Repository to guide the assessment, dispute, and appeals process
Business Impact
  • Established a digital repository of over 80 EIPM Program Policies
  • Each policy module includes up to 50 individual policy lines
  • Established change and content management workflows to track and approve policy changes
Key Accomplishment
Enabled a digitized complaints management workflow to address dispute resolutions and appeals process for stakeholders impacted by findings
Business Impact
  • Enabled auditable digital record system that is capable to track and manage over 200 stakeholder disputes and appeals per year
  • Enabled automatic notifications and alerts to reviewers
Key Accomplishment
Led the successful completion of the federal health agency's Security Assessment and Authorization (SA&A) for the EIPM Solution
Business Impact
  • Provisioned accounts for more than 50 users
  • Established a flexible architecture capable of adapting to changing regulations and requirements
  • Provided knowledge transfer and mentoring to agency staff to enable them to contribute to the support and maintain the Appian solution in the future
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