Success Story

How One U.S. Health Plan Rapidly Expanded in ACA and Medicaid Using Facets

Challenge: Leveraging Technology to Expand Product Lines and Serve More Members

Health plans have only a few options in order to grow: add members, expand into new geographic markets, and participate in governmental programs, like Medicaid and Medicare.

To make this happen, technology plays a major role. Benefit configuration, claims systems design, and data management all have to be certified and tested to offer health plan coverage in new markets. Without the right technology and the right people who understand that technology, growth is limited.

When it comes to finding configuration consultants with specific skills sets—especially those in development or functionally on the operation side—it’s nearly impossible to find individuals, let alone an entire team, who can quickly shift from one functional area to another and have the expertise to build out new product lines to support health plan market expansion.

When the client first approached us, they were in the process of converting their legacy claims system to TriZetto’s Facets platform and asked if we could assist with their new ACA (the “Affordable Care Act”) expansion, which had previously been delayed.

The client’s goal was to expand into multiple states with new product lines in order to rapidly grow their business. The COO asked us to configure Facets, so they could offer Medicaid coverage in a new state from the ground up, which has quite a bit of complexity.

None of their team members had experience with the new Facets system, and the team had no formal testing or documentation processes in place. To make matters more complicated, their project tracking system—which provides data on inventory and the status of work requests—was not configured properly. Thus, the executive leadership team had limited visibility into the management of the project.

Solution: Configure Facets to Expand into ACA and Medicaid Lines of Business

When SourcEdge first joined the team, we had to identify resources both inside and outside the organization that could be used to facilitate the transition.

From there, we assembled a highly skilled team with the ability to quickly shift between functional areas, analyze the situations, and come up with designs that would not slow down functionality.

As a team, we developed a project plan based on five fundamental steps:

  1. Requirements
  2. Design
  3. Build
  4. Test
  5. Deploy

SourcEdge’s Role: General Contractor, Mentor, and Software Engineer

Throughout the process, we worked hand in hand with the client as an integral part of their team. We mapped out the project plan for Facets along with timelines for each of the phases.

When we got to DHCP (Dynamic Host Configuration Protocol), our team stepped in to create a detailed project plan and schedule sessions to gather, collect, and document information, so we could configure Facets.

For the implementation of Medicaid, we analyzed 160 age-based fee schedules and determined a logical way to group them (Facets does not provide for age-based fee schedules). Since the program’s pricing and fees are also determined by taxonomy codes, we had to identify which of the fee schedules went with which taxonomy code. Then, we created 500 qualifier groups that Facets could turn into claim agreements based on the code.

For the ACA implementation, we spent a considerable amount of time mentoring employees across the board—from the call center all the way up to company executives. In addition, since the client had little to no usable documentation, we developed a detailed documentation process and helped them set up their storyboards, so we could support the work in the way they needed.

Outcome: Successful Market Expansion

The client was able to rapidly implement new product lines and expand into new markets in record time. As a result of this project, the client is no longer just a TPA (third-party administrator) on the exchange; they are now considered a fully qualified insurance provider (QHP).

As a certified Facets consulting organization, SourcEdge has the unique skill sets to deliver a turnkey, end-to-end solution to rapidly configure Facets to support new business growth.


2024 Cognizant Health Sciences Conference

SourcEdge, An Alivia Company, was Cognizant’s First Healthcare Certified Consulting Partner. During this four-day event, SourcEdge and Alivia Analytics will discuss its combined products and services for commercial and government health plans.