Self-Funded Billing

Administrative Services Only (ASO) is an arrangement in which an organization funds its own employee benefit plan such as a health plan but hires an outside firm to perform specific administrative services. For example, an organization may hire an insurance company to evaluate and process claims under its employee health plan, while maintaining the responsibility to pay the claims itself.

Self-Funded plan specifics vary depending on the agreement a company establishes with insurance companies and third-party administrators (TPA). In the self-funded plan, the insurance company may provide little to no degree of insurance protection. ASO services are gaining popularity because many employers, particularly larger ones, explore that the self-funded plan provides the potential financial advantages at an acceptable cost.

Oracle Revenue Management and Billing (ORMB) provides a complete solution in terms of pricing, billing, and revenue management to support the self-funded plans. It also provides risk coverage for offering self-funded plans through the stop-loss services, such as specific stop-loss and aggregate stop-loss. The specific stop-loss solution in ORMB helps the employer in mitigating high-cost claims for individual members. And, the aggregate stop-loss helps the employer in mitigating risk against high-volume claims.

The Transaction Feed Management (TFM) module is enhanced to support the self-funded billing. You can upload the claim, enrollment, and ancillary transactions in the system using the File Upload Interface feature. You can use the File Upload Interface feature to upload transaction data files in the following formats:

• Comma Separated Values

• JavaScript Object Notation

• Fixed Position

• Pipe Separated Values

• Tilde Separated Values

• Extensible Markup Language

Once the claim, enrollment, and ancillary transaction data files are uploaded in the system, you need to:

• Validate Header Details

• Validate Transaction Details and Determine Initial Price Item

• Verify Price Item Pricing

• Rate Transactions Before Billing (if required)

• Create and Update Billable Charge with the SQI values

• Clean-up Unwanted Data

The system provides the flexibility to rate the claim, enrollment, and ancillary transactions either prior to billing or during billing. Based on the business requirements, you can configure the system such that transactions mapped to a price item can be rated at a frequency which is different from the account's billing frequency. For example, daily, weekly, etc.

A new pricing model is introduced for the self-funded health insurance business which enables you to create pricing rules for:

• Claim

• Specific Stop-Loss

• Aggregate Stop-Loss

• Claim Based Fees

• Enrollment Based Fees

• One-time and Recurring Flat Fees

• Ancillary Charges

Once you create the required pricing structure, you can bill for the claim, enrollment, and ancillary transactions. Once the billable charges for claims, claim based fees, enrollment based fees, and ancillary are created through the transaction aggregation process, you can accumulate the specific stop-loss and aggregate stop-loss and create billable charges for them. Once the required billable charges are created, you can bill them using the charge-based billing batches.

Related Topics

Parent Topic: Oracle Revenue Management and Billing Insurance Business Processes