Data Integrity: ACA

Data Integrity Success Story: Affordable Care Act


The 115,000-member ACA plan was achieving a 98.5% submission and acceptance rate to the EDGE Server. The 1.5% in risk degradation resulted in a $7.7M suppressed risk transfer ($68 PMPY).


The health plan engaged Pareto’s Data Integrity solution to conduct a comprehensive evaluation of end-to-end data quality and identify points of failure to prioritize remediation. This solution is designed to recover lost data, improve processes by reducing CMS errors, and identify instances of incorrectly captured and submitted encounter information.


Pareto’s Data Integrity solution identified the following root causes of gaps in reported risk to focus remediation, resulting in a $7.7 million financial improvement opportunity:

$3.7 million

Subset of claims never submitted and inaccurately excluded $0 claim lines

$1.9 million

Claims paid after the 4/30 submission deadline that were not available for submission

$1.7 million

Unresolved claim-level errors received from the EDGE Server


Omission of select member policies and inaccurate adjustments for multi-policy members generating errors

While a point-in-time evaluation is valuable, ongoing monitoring is recommended to proactively identify and remediate data quality issues in advance of submission deadlines. This client is utilizing Pareto’s Data Integrity solution to conduct ongoing periodic evaluations throughout the year.

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