Case Study: Qualified Health Plan achieves accurate Cost Sharing Reduction (CSR) reconciliation and financial predictability with Infogix

Conquering Cost Sharing Reduction Special Cases

A regional Qualified Health Plan (QHP) with more than 140,000 members, owned by a large nonprofit hospital system, faced a critical gap: no in-house Cost Sharing Reduction (CSR) reconciliation solution and limited expertise to build one. Their vendor could not deliver in time for the first ACA year-end submission and could only address medical claims, leaving nonmedical claims and numerous regulatory “special cases” unresolved — a risk to accurate year-end subsidy reconciliation and financial forecasting.

Infogix implemented its Enterprise Data Analysis Platform to provide a full CSR reconciliation solution—capturing and profiling plan, claim and member data; performing lookups and standard-plan pre-calculations; handling special processing rules; and computing CSR values by claim line. The deployment delivered monthly estimated subsidy forecasts plus monthly and year-end CSR calculations for medical and nonmedical claims, giving the payer greater visibility, prevention of processing errors, configurability for plan quirks, and more accurate financial predictability at lower cost and faster timeline than an internal build.