Case Study 11.21.2017

Securing $715M in Risk Adjustment and Reinsurance

Trexin helped a Healthcare Payer capture $715M in Affordable Care Act payments for the 2015 benefit year.

Business Driver

As part of the Affordable Care Act (ACA), the U.S. federal government implemented multiple programs to mitigate adverse selection, allocate risk, and stabilize premiums in the individual and small group markets. Two of these programs, Risk Adjustment and Reinsurance (2R), proved to be crucial to Payers’ survival in the early days of the ACA.

Sensing that they were not maximizing their Risk Adjustment and Reinsurance results to the full extent allowable by regulations, our Client, a very large multi-state Payer, asked Trexin to lend its healthcare expertise on an extended year-long engagement to improve their performance for the 2015 benefit year.


Working under the sponsorship of the business solutions team within enterprise information management and analytics, Trexin quickly got to work assessing our Client’s operational processes and technologies in relation to best practices that Trexin applied at other Payer organizations that successfully mastered the 2R program. This gap analysis soon led to the identification of numerous opportunities for improving operational efficiencies. Trexin specifically focused on CMS rejected Enrollees, Enrollment Periods, Medical Claims, and Rx Claims, prioritizing our remediation efforts based on an opportunity matrix that we developed based on insights driven by our subject matter experts to maximize Risk Adjustment and Reinsurance results.

Throughout the process, Trexin provided expertise and guidance by facilitating numerous discussions for continued analysis of data, operational processes, business processes, ACA business rules, and audit requirements to determine areas of opportunity and remediating adjustments in upstream business processes, source systems, and existing code to enable more successful submission of data to the CMS EDGE server. To provide a foundation for continuous improvement, Trexin also helped our Client build various dashboards and reports to provide key insights into submission results and allow them to make strategic decisions that helped align their internal operational teams and prioritize efforts.


With Trexin’s expertise and assistance, our Client identified numerous deficiencies in operations, budget and staff, and immediately implemented corrective actions to strengthen their capabilities. Because of this project, a combined effort of IT and business operations, our Client successfully completed the data submission to HHS on-time in full compliance with the ACA 3R regulations. They also realized a remarkable payment of nearly $715M in Risk Adjustment and Reinsurance funds for the 2015 benefit year that they were not fully expecting.

Tagged in: Analytics, Healthcare, Optimized Operations
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