Softheon Helps Payers Prevent Unauthorized Third Party Payments

Health Insurance Technology Leader Announces an Extension of its Equity Solution to Address Growing Industry Demands to Prevent Illicit Premium Payments from Unprincipled Third Parties

STONY BROOK, N.Y. December 6, 2016 – Softheon, Inc., a proven leader in cloud-based health insurance exchange, has announced an extension of its Equity financial management and payment platform to help payers prevent illegitimate third party payments. This extension addresses industry concerns over the unethical practice of influencing consumers eligible for Medicare or Medicaid, into Marketplace plans to obtain higher reimbursement rates.


Currently, third party payments and cost-sharing of qualified health plans in the individual market is discouraged, but the ultimate decision about accepting those payments is left to health insurance companies. This extension to Softheon’s Equity solution gives payers more visibility to help address the problem proactively as regulations are finalized by the Centers of Medicare & Medicaid Services (CMS).


“While the concept of third party payments may not seem harmful at first, the reality is that third parties are paying premiums for low-income high risk patients for the sole purpose of obtaining higher reimbursement rates,” said Eugene Sayan, Founder & CEO of Softheon. “This not only impacts payers’ bottom lines, but it also disrupts the risk pool and increases the cost of care for everyone. While the CMS is currently determining guidance around third party premium support, Softheon has provided health plans the tools needed to address this issue in real-time, which is why we partnered with a leading financial institution to help solve this problem.”


Sayan will speak at length on the impact of third party payments on the health insurance industry, as well as premium billing in consumer-oriented digital healthcare on December 8th at the Millennium Alliance Healthcare Payers Transformation Assembly.


Softheon helps prevent affiliated payments using their automated lockbox service within its Equity solution. The feature enables Softheon to identify and classify various payments based on certain Magnetic Ink Character Recognition (MICR) and check characteristics. If a payment does not meet a payer’s criteria, or doesn’t match a member’s previous Accounts Receivable invoice, the payment will be pended for review. The payer receives an image of the payment and an explanation of why it was pended for review further.


Softheon’s Equity solution is a component of its marketplace suite, which is utilized by over 60 health plans nationwide and easily integrates with their core Administrative systems for a seamless experience for members purchasing health insurance through state and federal marketplaces. Softheon has maintained its position as a premier Business Process as a Service (BPaaS) solution in a highly dynamic industry. Recognized by Gartner*, IDC, AHIP, ACAP, HCEG, and other respected organizations, Softheon is the nation’s leading platform addressing the industry’s ever-changing regulatory demands.


About Softheon

Softheon was born from necessity. We came to the aid of companies that wanted to streamline their business processes out of a desire for greater efficiency, and after a few years focused in the healthcare space. Most of our clients had an existing process to address their needs, but in most cases these processes did not keep up with the times, making them more harmful than helpful. That's where we came in.


With the passage of the Affordable Care Act and the subsequent changes to healthcare landscape, we adapted our experience and technologies to facilitate carrier participation to the new direct-to-consumer sales channel. By partnering with our clients, and serving as an extension of their IT departments, we have learned a great deal about their day-to-day challenges and understand the close attention required for a mutually successful relationship. Now, with a new era of healthcare arriving, we are ready to help them adapt to any impending uncertainty.


*Gartner does not endorse any vendor, product or service depicted in its research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.


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