Insurers brace for ACA audits

Regulators will soon perform market conduct evaluations in five states

Regulators will soon conduct audits to determine whether payers comply with the Affordable Care Act (ACA), according to an article in LifeHealthPro

The National Association of Insurance Commissioners (NAIC) recently gave the Florida Health Insurance Advisory Board a briefing on the enforcement actions insurers can expect.

Federal teams already audit compliance with the ACA minimum medical loss ratio (MLR) provisions, according to a written version of the briefing.

However, regulators will soon perform ACA market conduct audits--or evaluations of how carriers treat customers, providers and other market players--in five unidentified states. Regulators could perform additional audits in other states, the NAIC staffers said.

In states in which the U.S. Department of Health and Human Services (HHS) run the ACA public exchanges, federal teams will look at the adequacy of exchange plan networks. Teams will also conduct general ACA compliance reviews, LifeHealthPro reports.

One way to pass muster with federal ACA auditors is to conduct internal company audits, advises the ​Internal Auditor.

A health plan's compliance officer will need to become "intimately familiar," with the ACA and stay on top of the changing laws that could pose a risk, the Internal Auditor reports. 

Experts say the main challenge auditors will face is the need to stay abreast of the changing laws to help identify risk and guide their organizations. They must also provide oversight and ensure that other departments in the organization maintain compliance and act within the bounds of the new laws, the article notes.

To learn more:
- here's the LifeHealthPro article
- read the National Association of Insurance Commissioners (NAIC) brief (.pdf)
- check out the Internal Auditor article

Related Articles:
Senate committee: CMS audits need improvement
State angers insurers with in-depth rate review audits
Medicare Advantage plans scrutinized more in CMS audits
UnitedHealth leads insurers to publicize rate hike filings