How to Comply with ACA-Mandated Spending Thresholds

There has always been pressure to “do more with less” and continually reduce operational costs. Labor costs is always one of the largest administrative costs for health plans and managed care payers. I’ve found this to be true in my past positions running health plan operations centers and it continues to be true today.

In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act (ACA) which mandated minimum Medical Loss Ratios (MLR) spending thresholds. If payers’ MLR spending is less than 80% for commercial lives and less than 85% for Medicare lives in each year, the difference between their actual MLR spend rates and the mandated minimum MLR spending thresholds for that year is required under ACA to be returned as rebates to those that paid the premiums (group employers, employees, individual plan purchasers, etc.). Because the MLR spending and rebates will always be at 80%/85% of premiums, this leaves only 20%/15% of the premium to be spent on administrative costs. This creates significant pressure on all health plans and payers to increase efficiencies in order to reduce operational costs. We expect these pressures to continue increasing as Medicare/Medicaid and health plan reimbursements decrease. This trend holds true for payers throughout the country, with no foreseeable end in sight.

Many health plans and payers have identified third party business process automation tools as the key to achieving their needed operational efficiencies. HCIM clients have been able to “work smarter not harder” using our SymKey® automation technology.

HCIM has licensed many new SymKey® clients in the time since ACA became law. We have increased the number of claims systems that SymKey® integrates with and are looking to expand onto three additional highly utilized core transaction systems over the next year. This is in response to the identified needs of new clients seeking to leverage SymKey’s technology to gain efficiencies and reduce operational costs.

For the past 13 years, SymKey® has delivered this valuable business process automation technology on a very cost effective basis, allowing clients to accurately and consistently process their claims while significantly speeding up their turnaround times. The lowered staffing costs allow payers to more easily keep their operational costs within the allowed administrative percentages after the mandated MLR spending rates and rebates.

SymKey® is truly a unique solution in today’s marketplace. Try it risk-free for 30 days to see how you can increase operational efficiencies and reduce administrative costs in order to remain within the 15%/20% administrative spending threshold. For more information, call 888-454-0202, option 5 or email

Michael Wilson, President and CEO of HCIM

Michael Wilson

President & CEO
HCIM Co-Founder

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.

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