The High Tech Behind Coordination of Benefits

July 13, 2018 Health Ideas Staff

When most people think of coordination of benefits, they envision those annoying letters from their health insurance company asking if they are covered by a spouse or other family member’s health plan. You know those letters that you ignore multiple times and finally answer the question when someone from the health plan manages to get you on the phone? Well, there’s another side to coordination of benefits that is high tech, efficient and moves the needle in terms of making the healthcare system more effective for individuals, healthcare providers and healthcare payers.

Today’s coordination of benefits, also known as COB, identifies and verifies an individual’s coverage as early as the point of enrollment, and often before that individual ever speaks with anyone from their new health plan. Using advanced matching logic and machine learning to smartly match coverage information to the correct individual has made the process of COB timelier, less invasive and more efficient. Terabytes of data are filtered and harmonized in a matter of minutes resulting in actionable outputs to healthcare organizations. Case in point, prior to a healthcare service being delivered or a claim being filed, both a payer and provider can get a clear picture of the patient’s available coverage across multiple plans and programs. This is important because it helps patients understand their available benefits and reduces the need for them to resubmit claims; it helps providers determine patients’ covered services and bill them correctly the first time, which improves the provider’s cash flow and lowers their administrative burden; and it helps payers to avoid paying improper claims while facilitating better care coordination considering their plan members’ full coverage benefits from multiple plans.

Sophisticated COB programs are also using artificial intelligence to score data given them the ability to identify claims that may be denied, and target which improper payments are likely to be recoverable. This enables focus on cases and claims that will deliver value, while cutting back on administrative costs related to rebilling, rework and denial management.

Today’s COB technologies help to eliminate both the data phishing and the manual processes that waste paper, time and resources; and since they operate more precisely in secure environments, the new technologies better protect sensitive data. Plus, they are integrated with eligibility and claims management systems to facilitate seamless process flows.

Coordination of benefits has come a long way in the past decade and innovations are happening daily. It won’t be long before that health plan coverage questionnaire is a thing of the past.

HMS is making strides to improve the healthcare system through COB innovations. What other healthcare processes have you recognized big changes in?

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