The Challenge
A multistate ACA health plan engaged ClearFile for standard regulatory filing support across three states, but the work quickly uncovered a much larger compliance issue: key benefit information was not consistently aligned acA multistate ACA health plan engaged ClearFile for standard regulatory filing support across three states, but the work quickly uncovered a much larger compliance issue: key benefit information was not consistently aligned across the plan’s source data, member documents, and regulatory filings.
The health plan was facing:
- Thousands of plan configurations across 20 states
- High volumes of inconsistencies across member and filing documents
- Prior financial penalties tied to noncompliant member language
- A manual review process that couldn’t support the volume of reconciliation required
Before ClearFile could simply complete the filings, the underlying documentation and benefit data had to be reconciled at scale.
The Solution
ClearFile quickly determined that correcting individual documents wouldn’t solve the underlying problem. The discrepancies were being created upstream, where product decisions, member materials, and regulatory filings were moving through separate teams without a reliable process for keeping them aligned.
ClearFile’s regulatory experts took on reconciliation across the health plan’s broader 20-state portfolio. The team reviewed SOBs, SBCs and EOCs against the intended benefit design, correcting discrepancies in cost shares, copays, benefit limits and other plan details across member materials and regulatory filings. In addition, the team completed 3,349 SBC scenario calculations to support regulatory submissions and finalized SBC documents.
ClearFile also redesigned the workflow connecting product strategy, member document development and filing operations, creating clear handoffs so benefit changes were carried accurately through each stage of the filing process. ClearFile technology centralized the documentation, workflows and filing activity behind that process, giving teams greater visibility and establishing a more organized foundation for future filing cycles.
Key Results & Client Benefits
The impact extended well beyond smoother filings. ClearFile helped the health plan reduce significant financial exposure, protect the integrity of its member benefits and build a more sustainable process for managing a high-volume ACA portfolio.
- $3.7M in estimated regulatory exposure avoided by identifying and correcting compliance issues before they could result in additional fees and costly downstream rework
- 32K+ errors reconciled across benefit data, member documents and filing materials, reducing the risk of inaccurate benefit information reaching regulators or members
- 5,373 plan documents reviewed and 3,349 SBC scenarios completed in three months, dramatically increasing the volume the team could manage during the filing cycle
- A repeatable reconciliation process established for future filing cycles, helping catch discrepancies earlier and reducing the likelihood that product, document and filing inconsistencies compound downstream
For a health plan managing an ACA portfolio across 20 states, the result was lower regulatory exposure, less costly rework and a stronger operating foundation for continued growth.
