Modern System Delivers Access to Essential Coverage for USFHP Enrollees

Introduction

The Uniformed Services Family Health Plan (USFHP), a contracted TRICARE health plan, provides essential coverage for eligible government healthcare beneficiaries. It has also proved to be an essential resource for helping the U.S. Department of Defense (DoD) Defense Health Agency (DHA) evaluate the feasibility and effectiveness of future Value-Based Insurance Products (VBIP). Data gleaned from the plan helps shape the DoD’s roadmap for implementing new VBIP programs around the world.

However, the effectiveness of this strategy hinges upon the collection, management, and analysis of vast amounts of up-to-date data, including enrollee information, clinical definitions, administrative data, and processing requirements. To ensure accuracy, all of this data must live within a modern system capable of integrating within the DoD’s broader healthcare ecosystem.

To bring USFHP’s legacy system up-to-date, DHA contracted Cognitive, through prime contractor Favor TechConsulting, to provide valuable subject matter expertise and Agile software development services.

Challenges

DHA’s move towards value-based insurance products aligns with the value-based incentive models adapted from the Centers for Medicare & Medicaid Services and other government programs. These models aim to reduce many of the barriers beneficiaries face in accessing essential healthcare—a process that depends upon the collection and analysis of realms of timely, accurate data on beneficiaries’ eligibility.

Existing on-premise systems lacked the capacity for integrations that could help DHA keep pace with changes to enrollees’ data. Every day, systems across DoD received information on address changes, family constellation changes, births, deaths, divorces, and more. Without access to this data, it was difficult for DHA to capture USFHP’s true value in connecting enrollees with quality care.

Cognitive was tasked with developing a software solution that could manage these changes, alongside all of the other information gathered for millions of Medicare, Medicaid, and international health program beneficiaries. The solutions would need to bring demographic, income, medical, household, claims history, and premium data together for use in complex algorithms that would verify eligibility. Moreover, data input in USFHP would need to be integrated with eligibility, enrollment, and appeals databases nationwide.

Solution

For the most timely, accurate transmission of USFHP enrollment data to the integrated DoD system, Cognitive knew DHA’s system would need to move from a traditional data center to a more modern enterprise cloud environment.By moving existing infrastructure to the AWS cloud, the team enabled an increased data analytics capability that would ultimately improve care outcomes.

The new system was designed to exchange eligibility, medical, and payment data, including required historical data, with the Defense Enrollment Eligibility Reporting System (DEERS), DoD’s database of eligible healthcare beneficiaries. This real-time exchange allowed the USFHP and DoD visibility into beneficiaries’ progress through the continuum of care.

Aligning data from multiple systems required the application of in-depth claims data reporting and audit-ready records. Fortunately, the software team’s experience with similar programs, including Medicaid managed care and the Children’s Health Insurance Program (CHIP) enrollment, provided a strong foundation and subject matter expertise. To maximize efficiency for system users, Cognitive automated the hierarchy assignment of multiple pieces of data and created a system for screening and correcting claims and appeals errors. The system also provided opportunities for users to quickly address anomalies or outliers and/or flag them for additional research.

Results

With these essential system updates, the Uniformed Services Family Health Plan is making significant strides in breaking down barriers to quality care. Cognitive’s approach enabled the USFHP system to process address changes, submitted forms, and account updates by the millions. This modernized system ensures that enrollees are reliably connected to the appropriate care whenever needed. As a result, military members and their families can now focus more effectively on force readiness and overall well-being, knowing that their healthcare needs are being addressed seamlessly and efficiently. This enhancement not only improves individual health outcomes but also contributes to the operational readiness of the armed forces by reducing healthcare-related disruptions.