Case Study: Exchange Enrollment Solved

Exchange Enrollment Issues Solved

Custom EMS software skyrockets efficiency for Common Ground Healthcare Cooperative in Milwaukee


Government-created health plan exchanges offer many benefits for qualifying patients. But for the qualifying health plans that administer coverage, such programs can be cumbersome. They are often challenging to adopt and manage on a daily basis.

The overall patient enrollment process remains fairly straightforward.

  • Individuals select a Plan option from a state or federal website.
  • An 834 file is generated and sent to the payer with details about the enrollee and his or her plan beneficiaries.
  • An employee at the Plan creates an enrollment record in the company’s system.
  • The Plan’s on-boarding process is initiated with the individual.

But “under the hood,” things can often be anything but simple, says Dave Pontrello, VP of EMS Healthcare Informatics.

“It works seamlessly in many cases, where enrollments are standard and executed within the proper windows. When the patient changes his or her mind, re-enrolls in a different plan or adds additional dependents or other variables after the fact, it can toss a wrench in the system,” he explains.

Discrepancies can occur.

Duplicate or triplicate records can result. Enrollment records do not necessarily get transmitted in the proper sequential order. A new plan enrollment can then occur before the old enrollment is terminated.

On the patient side, the on-boarding emails, letters and welcome kits already triggered can create great confusion. A family member may show up for an appointment and discover that he or she is not actually covered. Extra phone calls, emails and chaos can then result on both sides.

“This still happens more than payers would like,” offers Pontrello. “Most enrollment and claim management systems can’t have the same member in two different plans (conflicting 834 files) at once. It chokes the system, and records then need to be manually reviewed. Staff members dissect the potentially conflicting data and make adjustments. It squashes productivity and adds up in costs.”

How to Fix the Problem?

EMS was recently asked to help solve the issue for Common Ground Healthcare Cooperative in Milwaukee. Common Ground’s health plan serves patients in 20 counties. The answer? EMS developed an automated custom middleware solution.

“Our middleware sits between the 834s that the managed care plan receives, and the enrollment and claims management system they use,” explains Pontrello. “The EDI software analyzes the files received. A custom splitter divides them into types. The program automatically looks at the date/time stamps of each transaction. This determines the most current, accurate patient record. It then splits them into separate 834 enrollment files.”

Pontrello says that the transactions are then time-sensitive and sequential. This allows the client’s clam management system to then ingest them in an order that the system accepts.

Is it working?

“Common Ground’s client’s revenue cycle management team can now post nearly 100% of exchange enrollments automatically
with very little manual review required,” says Pontrello.  “We have helped to streamline the process, decrease the need for human intervention, and removed a major roadblock that was negatively impacting the bottom line.”

Looking for a similar fix or a custom software solution for a different issue?
Call EMS today at 716-626-3310 or email Dave Pontrello at

“We have helped to streamline the process, decrease the need for human intervention, and removed a major roadblock that was negatively impacting the bottom line.”

David Pontrello, EMS