CMS Demonstrates the Benefits of a Business Rules Engine

In this case explored in a Progress Corticon webinar, states struggling with the Affordable Care Act (ACA) learned the benefits of business rules engines (BRE).

The Affordable Care Act (ACA) required US states to update eligibility verification systems with new business rules within 30 months. Business logic that is hard-coded within government legacy systems would never be ready in time. Here’s how business rules engines (BREs) came to the rescue.

The CMS BRE Mandate

Government agencies often find themselves scrambling to make changes in software before new policies or laws take effect. The United States Affordable Care Act (ACA) is an excellent example of how legal and technical problems can converge rapidly to force organizations to remap IT to serve customers and stakeholders better.

As Dr. Mark Allen discussed last summer, the ACA mandated such a large list of changes that the federal government offered incentives for state agencies to replace legacy systems using hard-coded business rules with business rules engines like Progress® Corticon®.

72 million Americans receive health insurance through Medicaid and the federal Children’s Health Insurance Program (CHIP). The Center for Medicare and Medicaid Services (CMS) and CHIP support state agencies by providing policy guidance, audit and oversight, technical assistance and a 50/50 match for Medicaid, as well as reimbursement and funding assistance. The ACA required state eligibility systems to modernize to ensure that new, income-based eligibility for all Americans would be processed efficiently.

To ensure compliance by the day the ACA went into effect, CMS offered states participation in a federal financial participation (FFP) program. FFP guaranteed states that their modernization efforts to develop systems, operations and maintenance could be funded up to 90% if they met these specific BRE requirements:

• Use of open interfaces and exposed APIs
• Separation of business rules from core programming
• Availability of business rules in both human and machine-readable format
• Shared business rules

41 states wanted to receive FFP funding to design, develop and install a BRE, or enhance an existing one. At least half of them chose Progress® Corticon® to bring their systems in compliance.

Organizational Decisions Powered by Business Rules

Medicaid and CHIP representatives have to make hundreds of decisions every day. Should we pay this claim? Is this individual eligible for insurance? The rules that govern these decisions, such as “reject all claims with invalid billing codes,” are traditionally turned into decision logic hard-coded into applications.

A business rule engine separates decision logic from applications and represents them simply as rules. This enables IT, business analysts, actuaries and other decision makers to quickly update rules as policy changes without having to find decision logic among millions of lines of code across multiple integrated systems. The result is superfast processing and lower cost.

Think you don’t need BRE? Think again

To hear the full discussion of the multi-year project undertaken by state insurers and CMS, view the webinar replay: Modernization on Demand.

To learn more about Corticon, visit the website, contact us or try it right now.