CASE STUDY
MetricStream
Customer
A LEADING HEALTHCARE COVERAGE PROVIDER
Benefits
Assured compliance
MetricStream’s enterprise-wide compliance frame-
work along with regulatory alerts integration and
automated control management enables the company
to ensure complete compliance with the plethora of
regulatory requirements extending across NAIC MAR
and CMS. MetricStream Solution eliminates compli-
ance gaps and inconsistencies at every step, ensur-
ing a fool-proof approach to compliance. It also helps
the company seamlessly evolve with the compliance
landscape and respond readily to future changes in
regulatory requirements.
Automation of critical workflows
MetricStream Solution eliminates the need for manual
processes, spreadsheets and paper-based applica-
tions. The solution is equipped with the business
intelligence to automatically track regulatory updates,
monitor internal controls and raise alerts when issues
occur. This way, the company will be able to improve
the efficiency of compliance management processes
and save valuable time, costs and effort.
Enhanced collaboration and visibility
MetricStream Solution helps the company shift from
an ad hoc compliance approach to an integrated,
one. It extends across business silos to streamline
compliance management across the enterprise and
improve collaboration. Powerful dashboards deliver
enhanced, real-time visibility at every stage, enabling
the company to make informed decisions regarding
compliance.
Improved accountability
MetricStream Solution helps the company embed a
culture of accountability and compliance. It supports
independent management of assignments and has
the capability to roll information back up to higher
management for enhanced visibility and decision
making. This way, the company will be able to closely
monitor loopholes in compliance and apply the ap-
propriate remediation measure.
A MAJOR BCBS AFFILIATE STRENGTHENS ITS HEALTHCARE
COMPLIANCE THROUGH AUTOMATION AND INTEGRATION
Customer
The customer is an independent licensee of the Blue Cross Blue Shield Network and is one of the larg-
est providers of healthcare coverage in a US state.
The company is committed to improving the wellbeing and health of its community through affordable
health plans, employee benefit services and wellness programs.
Overview
The healthcare industry has witnessed sweeping regulatory reforms over the last few years. From the
Affordable Care Act to the Model Audit rule (NAIC MAR) to mandates from the Centers for Medicare
& Medicaid Services (CMS), compliance regulations have only increased in scope and number. Health
plans cannot afford to slack as regulatory scrutiny is intense and noncompliance penalties are high.
However, compliance is not only a matter of appeasing regulators. A robust compliance program can
lower the incidence and impact of risks, help overcome crises and build higher brand loyalty.
Fueled by the desire to offer access to top quality healthcare, the company is committed to develop-
ing a world-class risk and compliance management framework. It has already incorporated a number
of standards and procedures to reward quality healthcare and minimize medical errors. However, en-
suring compliance with complex regulations such as NAIC MAR and CMS can be daunting especially
with regard to tracking regulatory updates and monitoring compliance.
As the number of compliance requirements increased, the need of the hour was for a robust system
that could strengthen the company’s existing compliance strategies, mitigate risks and protect the
interests of patients and stakeholders.
Challenges
Manual tracking of regulatory updates
With external regulations frequently changing, the company had to consistently keep abreast of all
updates and alerts. Most of the time, these alerts were tracked through manual spreadsheets and
paper-based processes, and then forwarded to the respective managers across the enterprise. The
entire process was time-consuming and laborious. Besides, it was impossible to ensure that all
updates across all required regulations were being tracked at all times.
Increasing compliance requirements
As a health plan, the company is confronted with a growing number of compliance regulations includ-
ing NAIC MAR, HIPAA, the Affordable Care Act and other CMS regulations. Each regulation comes
with an enormous list of requirements and demands. For NAIC MAR alone, the company needs to
demonstrate compliance with over 500 requirements. It’s an extremely cost-intensive, time-consum-
ing and laborious process – one that is prone to errors especially when conducted manually.
Ad hoc compliance Initiatives
Being a large organization, the company managed its operations – including compliance – in func-
tional silos and ad hoc systems. There was not much collaboration across units, departments and
locations. As a result, compliance activities would often result in redundancies and duplicities. The
same risk across two departments would have multiple controls. This was costly, inefficient and un-
necessary.
Building a culture of accountability
In addition to external regulations, the company has its own policies and ethical Standards such as
monitoring employees’ use of social media. Ensuring sustainable compliance with these standards
and building a culture of accountability requires a centralized view of enterprise-wide compliance.
Without this, the company would find it complex to consistently monitor compliance at every turn and
resolve sensitive issues.
MetricStream
Lack of a centralized repository for policies and documents
Like other health plans, the company is required to manage a large amount of documentation related
to company policies, compliance requirements, control assessments and more. Sifting through these
documents and extracting the required information at the right time is difficult when each department
functions independently and stores their own documentation.

Solution
The company wanted a solution that could help embed and sustain a compliance-focused work
culture. The solution was required to automate and streamline critical compliance workflows, while
providing a common platform to integrate compliance management across the enterprise.

After considering several compliance solution providers, the company selected MetricStream based
on its domain expertise and rich solution capabilities, as well as its successful track record with
several other BCBS affiliates.

MetricStream provided the company a comprehensive healthcare compliance management solution,

equipped with capabilities for regulatory alerts tracking, policy and document management, and issue
management. Using the solution, the company will be able to assure compliance with regulatory
requirements, thus enhancing stakeholder confidence and protecting the interests of its customers.

Regulatory alerts tracking

MetricStream Solution seamlessly integrates with regulatory sources such as CMS and the Health
Plan Management System (HPMS). This helps the company track regulatory updates through vari-
ous channels such as the Web, e-mail and RSS Feeds. The solution captures all relevant regulatory
information and stores this in the form of a centralized repository that can be accessed by the relevant
stakeholders.

Subsequently, the solution helps in interpreting these alerts and updates, keeping stakeholders
informed and initiating an issue and action plan.

Compliance Management
MetricStream Solution enables the company to comply with the complete spectrum of healthcare
regulations, including NAIC MAR and CMS mandates. The solution provides a centralized structure of
the overall compliance and control hierarchy, including processes in scope, risks for the processes,
controls to assess the risks and mechanisms to assess the controls.

At each point, control assessments are easily scored, tabulated and reported. They are also monitored
based on predefined criteria and checklists.

The solution contains powerful reporting capabilities to aggregate control assessments and compli-
ance data into comprehensive reports. It enables the company to track compliance patterns, study
and analyze compliance trends, and focus on those areas that require immediate attention.

Issue Management
MetricStream Issue Management Solution helps the Compliance & Ethics group track, investigate and
resolve sensitive noncompliance issues.

All issues including potential noncompliance issues trigger the issue management and remediation
mechanism. The system then investigates, analyzes and documents the issue, and routes it to the
required personnel for further investigation.

Automatic alerts track the progress of the issue remediation process and ensure that the company re-
solves each issue before it is closed. At every stage, executive dashboards allow managers to closely
track the issue as it moves from one stage to the next.

Policy and Document management
MetricStream Compliance Management Solution is equipped with a centralized repository for all poli-
cies, compliance requirements, control assessments, regulatory updates and other critical informa-
tion. It provides the company with a single, secure data location for easy access and storage. Rights
to view, modify, distribute, or print are granted based on roles and user groups.
MetricStream
Why MetricStream
MetricStream’s vast domain experience of imple-
menting GRC solutions for some of the largest health
insurance companies and BCBS affiliates
The solution’s ability to track regulatory changes and
follow them up with an appropriate action plan
The solution’s ability to comply with a spectrum of
regulations such as NAIC MAR, HIPAA/HITECH, and
other CMS regulations
Enterprise GRC Platform
MetricStream Solution is built on a GRC platform which meet’s the organization’s objective of extend-
ing the solution across business units, operations, departments and geographies. The platform
provides built-in tools such as a Form, Process Flow and Data Designer that can be configured to suit
specific business requirements. It helps the company streamline and integrate compliance manage-
ment across the enterprise.
The platform also enables the company to adopt a clear, unambiguous approach to compliance by
breaking down restrictive silos and building more collaborative workflows. It provides a centralized
framework to manage all compliance processes ranging from control assessments and monitoring, to
risk analysis, to reporting, to documentation.

The solution’s ease of use and scalability which

enables it to be extended across the enterprise

The solution’s flexibility to be configured to the

customer’s specific requirements with minimum need
for programming

Automated workflows ensuring collaboration with

various stakeholders

For more information, visit

www.metricstream.com

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