Coordination of Benefits (COB)
A member files a claim, your COB vendor checks to see if the member has primary coverage elsewhere, and you deny the claim or recoup the amount paid if they do. Super simple, right?
Making that match is a complex affair that involves:
Data. Lots of it.
To be truly effective, coordination of benefits requires the aggregation of huge amounts of data in various formats from multiple sources. Because members’ healthcare coverage changes frequently and fast, your data needs to be constantly refreshed to be of any use.
The data should cover all claim types. Having only medical or only pharmacy will compromise results. Full, robust feeds of medical, pharmacy, behavioral and more is needed to identify all third-party coverage. And you’ll need data from all the major national health plans, but to ensure the best match possible, you’ll need all of the state and regional plans too.
Data use agreements with all of these agencies and companies take time and effort to establish. Make sure that they are already in place before you engage a vendor.
You’ll want a partner who will take your member and claim data in whatever format you have it. You don’t have time to work on integrations. And when your match results come back to you so that you can streamline your process in the future, you want that data to be in a format that you can ingest to your system without any fuss.
Once you’ve got your data, you need to do some clever stuff with it. For that you’ll need:
It’s pretty straightforward for any decent COB vendor to identify a Medicaid member who lives with their spouse and has coverage through that spouse’s job.
It requires considerably more insight to find active insurance for a child living with her father in Wyoming, whose coverage is available through her non-custodial mother who moved to Texas two months ago, is listed as Meredith in some in some records and Edie in others, and now goes by her maiden name. Most vendors would miss that one. It takes advanced matching logic that incorporates thousands of algorithms focused on common names, family connections, cross state matches and more to identify most third-party liability matches.
The most sophisticated COB solutions employ machine learning to smartly connect coverage information to the correct individual. Modular frameworks and API connectivity have made the process faster, more efficient, and have created a host of integration points. Artificial intelligence is being used to score data, providing the ability to target erroneous claims most likely to be recoverable.
Being smart isn’t enough, though. Your solution needs to be flexible and fast, too. To be effective you’ll want to look for coverage at enrollment, prior authorization, point of billing, adjudication and post-payment. It’s particularly important to discover primary coverage at enrollment—this is typically a time of high utilization as a member addresses issues that have gone unexamined while it was believed they didn’t have health insurance.
And while a match in 24 hours is good, and will prevent erroneous payment at enrollment, there are times when you need results almost instantly, such as a prior authorization for a costly emergency radiology exam. Make sure your vendor can provide this level of service.
Catching an improper claim before it hits your bottom line is always the ideal, and COB leaders get better at that every day, but sometimes, due to lapses in coverage reporting and other factors, you may have to recoup a payment after it is made, so it’s important that your COB solution is capable of addressing post-payment recovery.
These recoveries can sometimes cause member or provider abrasion, so it’s important that you have:
Great people with deep experience
The COB team members who work on your behalf represent your health plan or program, so it’s crucial that they display empathy, knowledge and intelligence when interacting with your stakeholders. It takes time to develop these traits, so look for a vendor with a solid history and low turnover.
Keep these considerations in mind when looking for a coordination of benefits partner and you will enjoy a relationship that helps your organization maximize cost savings and operate at peak efficiency.