The Vital Role of Coordination of Benefits in Coordination of Care

September 4, 2019 Health Ideas Staff

The concept of care coordination is inherently broad — so much so, that a review by the Agency for Healthcare Research and Quality (AHRQ) found more than 40 definitions of care coordination and similar language, from which it developed the following working definition:

“Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”

While coordination of care remains somewhat of a blanket concept, the AHRQ definition makes one thing clear: that integration is fundamental to the success of personalized, team-based healthcare models, in which all parties must be aligned in the goal of improving outcomes and containing healthcare costs.

True care coordination requires a high level of interorganizational integration to facilitate the seamless exchange of patient health information, including all sources of health coverage, across all necessary stakeholders.

Understanding & Maximizing Multiple Sources of Health Coverage

The proper coordination of benefits is essential not only to healthcare cost containment efforts for payers and providers, but also improving the coordination and delivery of care for individuals with access to more than one coverage source.

Whether an individual is dually enrolled in Medicaid and Medicare or has access to both government and commercial health benefits, knowing the full scope of available coverage prior to care or billing helps care teams operate more efficiently and increase patient satisfaction by maximizing use of all coverage sources.

Bridging Gaps in the Care Continuum

With coordinated and value-based care structures emerging as a means to overhaul inefficiencies associated with fee-for-service arrangements, care teams are employing a whole-person approach that integrates physical, behavioral and social determinants of health to provide higher quality, higher value care.

While coordinated care models are theoretically designed to improve the delivery of care for all individuals, perhaps their greatest potential lies in comorbid patient populations, for which care is generally longer term and more complex. According to HHS, approximately one in four Americans has two or more chronic conditions — three out of four over the age of 65 — comprising more than 65 percent of total healthcare spending in the US.

Many individuals with multiple chronic conditions are eligible for coverage under multiple health plans — commonly, through Medicaid and Medicare. Of the 12 million dual-eligibles CMS reported in 2017, 60 percent had multiple chronic conditions.

Though several coordinated care plans have been developed to address this critical population, only a small percentage of dual-eligibles are actually enrolled in these plans, which places the time and labor-intensive responsibility of coordinating Medicare and Medicaid benefits in the hands of healthcare organizations — and the responsibility of reporting all coverage sources largely in the hands of the patient.

Facilitating Better Care Coordination for Payers, Providers & Patients

Without the intelligent integration of patient health data across various sources, understanding a patient’s full range of health benefits can be more than a heavy administrative burden — it can be a barrier to healthcare for vulnerable populations. Services covered by commercial health plans versus Medicaid versus Medicare varies widely. If a patient who is eligible for multiple plans and / or programs reports only one source of coverage, they can be denied vital services that they actually qualify for. Moreover, when coordinated properly, the patient will typically have lower out of pocket costs when using their full coverage available to them. For example, Medicaid will cover certain co-pay and deductible expenses for qualified recipients who also receive coverage under a commercial health plan.

True care coordination requires interoperability and alignment across all aspects of care and at all stages of the patient journey — from health plan enrollment to onboarding through long-term care management. As the industry shifts from fee-for-service to fee-for-value, coordination of benefits programs will continue to play a key role in enabling providers and payers to achieve the triple aim of enhancing the patient experience, improving the quality of care and reducing healthcare costs.

With the help of technology, healthcare organizations are proactively identifying all coverage sources prior to the point of care, allowing providers to operate with a full understanding of available benefits and enhancing efficiencies across the care continuum.

How are you integrating coordination of benefits into your coordinated care efforts?

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