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Streamline MAPD Reconciliation Operations & Deliver Actionable Results

SyncRecon

SyncRecon™ is a comprehensive suite of full-service tools designed to streamline MAPD reconciliation operations and deliver actionable results. Crafted from decades of experience in healthcare operations, SyncRecon™ is modular, queue-based, business-rules driven, and continually updated to reflect governance changes and best practices. All modules can be implemented independently or combined as a bundle to enhance or replace your existing tools.

The SyncRecon™ suite includes the following modules:

Other Health Insurance (OHI): combines the MSP & COB modules to optimize data management of the CMS Part C & D COB records to produce clean validation records. Our advanced business rules identify duplicates, filters out unusable data, and reduces non-actionable discrepancies/cases.

  • Medicare Secondary Payer (MSP) Module 
    Uses CMS’ Part C MSP file to identify all possible records of capitation recovery and validation. Removes duplicates, efficiently groups records, tracks ECRS submissions, and reconciles primacy flags in a claims payment system. Pairs with the COB module to increase efficiency and identify overlaps in CMS files.
  • Coordination of Benefits (COB) Module
    Uses CMS’ Part D COB file and customizable business rules to identify new enrollees and annual records within the CMS regulatory timeframe. Supports updates to downstream claim systems. Mitigates risk, increases accuracy, and decreases admin costs.

Monthly Reconciliation Process (MRP): combines the Monthly Membership Report (MMR), Monthly Premium Withholding Report (MPWR), Late Enrollment Penalty (LEP), and Low-Income Subsidy (LIS) modules to satisfy CMS requirements on Reconciliation of Plan Data with CMS Data.

  • Monthly Membership Report (MMR) Module
    MMR = CMS Source of Truth. Identifies discrepancies between Plan Membership data and CMS’ MMR—enrollment mismatches, demographic, contract, status and PBP discrepancies. Mitigates historical data (36-months) and performs reconciliation on prior years.
  • Monthly Premium Withholding Report (MPWR) Module
    Performs a rolling 36-month reconciliation for members on SSA/RRB withholding—identifies member billing issues resulting from premium payment option discrepancies between plan systems and CMS.
  • Late Enrollment Penalty (LEP) Module
    Identifies gaps in plan administration and premium billing processes. Validates retroactive reporting—identifies discrepancies in totals, changes, and removals, compared to the invoices and premium billing system. Detects instances where LEP letters need to be sent.
  • Low Income Subsidy (LIS) Module
    Reconciles subsidy and cost-sharing levels with plan premium billing system and Pharmacy Benefit Manager (PBM). Decreases overrides at pharmacy point-of-sale and Prescription Drug Event (PDE) rejections due to inaccurate cost-sharing. Maintains accuracy for CMS’ monthly reconciliation requirements.

Retro Processing Contractor (RPC): combines the RPC Submission & Tracking Module and the Enrollment Data Validation (EDV) Submission Module to streamline the CMS-RPC process.

  • RPC Submission & Tracking Module
    Reduces errors and rejections by the systematic creation of archivable required documentation worksheets, submission packets, cover letters, and submission spreadsheets.
  • Enrollment Data Validation (EDV) Submission Module
    Creates WorkSync transactions from the monthly EDV audit spreadsheets which are uploaded into the module and assigned to users. Generates required documentation worksheet and full EDV packet to ensure a complete submission.
  • Attestation Reporting
    Tracks all discrepancies identified within the Monthly Reconciliation Process and provides Executive Summary Reporting to support the Quarterly CMS Certification requirement.

Daily Operations Management (DOM): combines the TRR Processing, OOA and SCC Change Management & Tracking, and Letter Management services to streamline the process and provide the best outcomes.

  • Daily Transaction Reply Report (DTRR) Processing Module
    A comprehensive client-specific TRR matrix was developed to identify actionable TRCs, route them into manual/automated work queues, and provide tracking to ensure compliance.
  • Out of Area (OOA), State & County Code (SCC) Change Management & Tracking
    Manages multiple sources of possible OOA status including notifications from call centers, claims, providers, returned mail, and in-area SCC notifications.
  • Member Correspondence/Letter Management
    Populates time-sensitive CMS-approved letter templates generated upon receipt of a TRC or triggered manually by a user—accommodates new enrollments, denials, and cancellations.