How Payers & Providers Can Work Together to Improve Coordination of Benefits

August 6, 2020 HMS

The ongoing COVID-19 crisis has created widespread challenges and uncertainties across the healthcare spectrum.

In addition to health concerns stemming from the coronavirus itself, millions of healthcare consumers have lost employer-sponsored insurance as a result of the pandemic, leaving them to navigate the complexities of the health insurance ecosystem.

For Medicaid agencies, COVID-19-related layoffs and furloughs have driven a surge in enrollment during a period when state budgets are exceedingly strained.

Providers, especially those in hard-hit areas, face an onslaught of challenges, from coding, billing and regulatory changes to varying capacity utilization issues resulting in financial stress.

In today’s healthcare environment, the mantra, “we’re all in it together,” rings especially true, as payers must balance payment accuracy activities with efforts to mitigate the heavy burden on front-line providers.

Uniting Payers & Providers Around Coordination of Benefits

One area that would benefit from a more collaborative approach is coordination of benefits (COB). When a person has more than one source of health coverage, COB determines which payer is primarily responsible for paying a claim. This ensures consumers are receiving access to the full range of their health benefits, while protecting Medicaid as the payer of last resort.

Although COB has historically been regarded as a payer function, innovations in COB technology are affording providers immediate access to coverage information at various points throughout the care continuum. Knowing which payer to bill prevents improper payments from occurring, helping to preserve Medicaid funds for those who need them most and reducing the administrative burden of reworking claims — a win/win for payers, providers and consumers.

Reducing Provider Burden Amid Today’s Crisis & Beyond

Enabling providers to access COB information during this period of uncertainty — and in its aftermath — can help streamline workflows and maximize revenue at a time when resources are strained. As providers in many areas face an influx of COVID-19 patients as well as pent-up demand for knowing which party to bill is crucial. Due to current economic conditions, many patients may have been displaced and have a higher chance of being Medicaid eligible or considered self-pay — information providers need in order to effectively coordinate care.

Facilitating Payment Accuracy

With state budgets under severe strain, getting payments right has never been more important. By equipping providers with COB information when they need it, healthcare organizations are better positioned to pay the right claim in the right amount, reducing both overpayments and the amount of pay and chase activities required. This is imperative as organizations must focus reduced staff resources on serving members with critical enrollment, accessibility and benefits processes — not pay and chase.

It’s Time Payers & Providers Work Together to Coordinate Benefits

Medicaid spends billions of dollars each year paying improper claims. Giving providers access to on-demand coverage data prior to authorization, billing or care helps to ensure everyone has the information they need to accurately authorize, schedule and bill for healthcare services. When payers and providers work together to continuously verify this information throughout the care continuum, it helps to expedite the reimbursement process, while improving the bottom line for both payers and providers — considerations that are more important than ever in today’s environment.

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