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What is the Perfect Compliance Prescription for Insurance Organizations?

  • by Computer Services Inc.
  • Jul 27, 2017

Today, health insurers run an enormous risk if they are not regularly screening against OFAC and other sanctions lists and complying with know your customer (KYC) rules. Further, they suffer the additional scrutiny of Medicare and Medicaid lists that vary with each state, creating a uniquely complex regulatory environment.

Few understand this environment better than LeeAnn Ellison, Medicare liaison for Blue Cross Blue Shield Nebraska.

“Due to the dynamic global climate, it has become imperative to be able to view those individuals with whom the federal government requires us not to do business with. Tougher, ever-changing criteria must be met at a moment’s notice,” Ellison says.

But what is the solution—or rather, the prescription—for dealing with these unique regulatory requirements in a timely manner?

For health insurers like Blue Cross Blue Shield Nebraska and Premera Blue Cross (below), the answer is a holistic sanctions screening tool, one that enhances the efficiency of their compliance programs.

 

An Automated Process

Increasing regulatory pressure has become commonplace in the American insurance industry, and it’s likely to stay that way—if not become even more stringent. Sanctions screening in particular has become a pressure point as OFAC and other regulatory agencies continue to target insurance providers.

Despite this increased pressure, many of today’s health insurers rely on manual processes to weed out potential sanctioned individuals. This is blatantly problematic for two reasons: manual processes are painfully slow, and they increase the likelihood of human error.

That’s why Gena Rooney, senior compliance and ethics program administrator for Premera Blue Cross, decided to implement an automated sanctions screening solution, to great effect: “In the last three years, since I’ve started using the program, I reduced the amount of time it takes to complete my sanction reviews, on average, from one week a month to less than a day.”

Automated sanctions screening solutions have the ability to screen a name in less than one second, all while maintaining complete accuracy. These automated processes reduce the insurer’s risk while decreasing the operational burden of manual screening processes.

 

All Applicable Lists

Health insurers must also be mindful of the tedious nature of in-depth screening processes.

With sanctions compliance demanding so much time and receiving so much scrutiny, health insurers can’t afford to process one faulty claim or insure one sanctioned individual. Yet screening efforts cannot disproportionately burden the operational effectiveness of the insurer; the solution is finding the delicate balance between operational effectiveness and risk tolerance.

So the benefits of having all of your sanctions screening requirements flowing into one system, which has the capacity and capability to screen against all relevant sanctions lists, are immeasurable.

Health insurers with differing regulatory requirements must afford themselves this flexibility, as regulatory conditions can change rapidly.  

 

Reduce False Positives

False positives have the potential to wreak havoc on the operational effectiveness of a sanctions screening program—especially if that program is manual. False positives occur when certain names on a sanctions list are confused with legitimate customers.

For an automated, centralized sanctions screening system, however, false positives do not pose as great a threat, as Rooney explains:

“By using the features available within the program, one can eliminate the need to re-review the same individuals every month and truly focus on those individuals/entities that are new, or have experienced changes in their profiles.”

Automated screening tools bring more efficiency to health insurance compliance programs, helping simplify sanctions screening requirements. Such tools are especially important as both businesses and regulations increase in scope and complexity. To find out more about the steps health insurers can take to implement automated compliance solutions, take a look at our Blue Cross Blue Shield Nebraska/Premera Blue Cross case study.  

 

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