Methods to construct a precious coordination of advantages program

A profitable coordination of advantages (COB) program can lower medical prices, enhance member relations, and keep away from supplier abrasion by rapidly figuring out the right order of advantages for even probably the most advanced claims. However many fee integrity applications lack the required assets in bandwidth, information analytics, and enterprise guidelines to coordinate profit funds precisely and effectively.

On the fourth episode of our Fee Integrity Insights podcast, Cotiviti’s coordination of advantages (COB) leaders focus on:

  • The significance of getting a complete strategy to COB to maximise worth
  • The variations between member-based versus claims-based methods
  • The constraints of relying solely on member eligibility information
  • The methods for optimizing COB applications, leveraging inner groups, member information, and the experience of full-service COB companions to assist guarantee effectivity and financial savings

Do not miss this chance to streamline profit coordination and stop incorrect funds by optimizing your fee integrity program with sturdy information analytics and business experience. Keep tuned for future episodes of Fee Integrity Insights on Apple Podcasts, Spotify, and anyplace else that you simply get your podcasts.

Podcast friends

EvanOkulanis Evan Okulanis
Vice President, Coordination of Advantages
Blog_Chris Ellsworth Chris Ellsworth
Director, Fee Integrity Progress

Podcast transcript

Chris: Right here at Cotiviti we work with over 100 Health plans, so we’re capable of take a holistic view of market traits together with what we’ll be speaking about at the moment, and that is the coordination of advantages (COB) world. So let’s start by speaking about a few of the market environments for our Health plans and the way this impacts their coordination of advantages applications from high to backside.

We see rising healthcare prices and growing medical loss ratios, and our shoppers are extra involved about medical loss ratios (MLR) in 2024 than they could have been a yr or two in the past. As we exited the pandemic, there is a shift in price constructions from suppliers struggling financially, and now with elevated consumption and elevated prices, we see that MLR quantity begin to enhance and elevated dramatically for our payers. And together with this, we additionally see elevated administrative price pressures constructing in addition to competitors throughout the Health plan world as an increasing number of payers begin to enter into the setting as properly.

We see payers involved with each member and employer group satisfaction as they attempt to hold that enterprise and proceed to offer that high quality care to their members. And there is additionally the supplier relationships that plans have to juggle and handle. Payers have to hold suppliers glad to assist appeal to these suppliers and retain their networks. So all of this results in plans needing to make massively influential and essential enterprise choices throughout fee integrity, but additionally particular to the world of coordination of advantages.

We see there are a number of distributors providing a wide range of options. Some are software-only, some are managed options, they usually are available at completely different value factors and completely different service ranges. And payers are tasked with in search of the fitting stability of each insourced and outsourced intervention factors to assist clear up their issues within the coordination advantages world. So Evan, with that background and from our standpoint and our imaginative and prescient throughout the business, what are a few of the issues that stand out to you after we discuss concerning the COB pressures that plans are dealing with in addition to a few of the options that we see?

Evan: COB is fixed. IT‘s not one thing you carry out simply as soon as. A member’s life is continually altering and issues are occurring the place you may’t simply carry out COB on the preliminary enrollment of a member. There are additionally situations that exist for overpayments that occur in small timeframes that yield nice worth. IT requires a relentless want to watch your membership, and that information you require is not at all times available in entrance of you.

You additionally want to remain present and in compliance on a number of completely different COB methodologies associated to member with Medicare Secondary Payer (MSP) and Nationwide Affiliation of Insurance coverage Commissioners (NAIC) tips in addition to state interpretation, but additionally declare for COB methodologies of declare adjudication and processing. Along with that, COB is not only utility of a coverage—you must supply your Information from someplace. Not solely do you must supply that, you must apply that rule and carry out coordination of advantages and restoration actions the place relevant. With that, how do you go about confirming COB so that you seize IT rapidly, precisely, and in a means that leads to a clean member and supplier expertise? Lastly, how do you’ve got confidence you’re capturing all the pieces for coordination of advantages?

Chris: That is attention-grabbing. From what I am listening to, there’s a whole lot of completely different shifting items and we’ve got shoppers that are available with all various kinds of ranges of COB applications and we hear Health plans say that they could be doing a little piece of this internally. Why cannot a plan simply do that themselves? Or why cannot they only select an easier possibly a software program solely choice?

We see that our shoppers usually must reply to senior management on financial savings initiatives and numbers throughout fee accuracy together with COB, and we’re usually requested to rationalize and visualize a few of the usage of a service vendor versus an in-house or a software-only answer. And we perceive that when there is a price line added to the equation, there’s going to be extra eyes watching that piece of that puzzle. So with that background in thoughts, we’ll be speaking about a few of the components that plans want to contemplate in constructing a profitable coordination of advantages program and what that worth creation from auditing for different coverages appears to be like like when a plan is working with a COB vendor.

So plans having enrollment and entitlement information both in-house or from an exterior information supply and the way that information supply alone may not be sufficient for plans, and the way they could be handcuffed by a leads-only strategy to COB overpayments and fee errors that also requires analysis, validation, outreach, and restoration to all be carried out by a restricted useful resource. Evan, in your expertise, are you able to speak about this a bit bit extra—that inner DIY information evaluate and why that may not be sufficient for a full COB program worth?

Evan: With the entitlement or enrollment information belongings as properly, these have been round for a very long time, some across the previous decade, however some even round for longer. There’s nonetheless a pattern that we’re seeing extra usually being promoted that these information belongings alone are what makes a COB program. These belongings are clearly precious; they give you an excellent image and an excellent window to start your investigation, however as you introduced up, they’re only a lead. They nonetheless require a big quantity of effort to evaluate and keep.

However for lots of our plans, the variety of data that is accessible for them is insurmountable. You do not essentially have the assets available to help a whole bunch of hundreds of data to have the ability to keep all of these and seize the chance that is wanted for COB as properly. As well as, the info on these belongings could be incomplete or outdated and even invalid, that means they cannot be absolutely automated and also you’re expending your assets on investigations that are not at all times yielding worth and you are not attending to what these belongings do not present you as properly.

Whenever you are likely to focus purely on the info belongings for a COB program, you miss out on worth. For payers we help at the moment, we discovered that 40% of our industrial different insurance coverage findings aren’t even on CAQH’s COB Sensible file. That is essential for our plans and companions to grasp as simply within the industrial different insurance coverage area alone, you not solely have to help investigation restoration effort on CAQH’s information, but additionally work to handle the rest of alternative that exists past that. And that is simply industrial different insurance coverage. IT would not even embrace Medicare as the opposite insurance coverage as properly. It’s essential to ask how one of the simplest ways to sort out that’s.

Chris: So let’s unpack that a bit bit extra and focus on that. So past the flexibility simply to leverage a plan’s inner information belongings, what do you have a look at for plans to get probably the most out of their COB program?

Evan: A profitable COB program would not cease with leveraging an information asset to get the complete image. Like we talked about, these recordsdata are a whole lot of information and they’re robust leads, however they depart open a pool of alternative inside themselves, but additionally with out IT. Along with that, information, like we talked about, is ever altering. As a member’s life proceeds, issues change. A life occasion corresponding to a delivery, a wedding, an sickness could change a COB state of affairs and you will not have the ability to seize that overpayment with simply leveraging an asset. So a type of circumstances that require evaluate, before everything is investigation based-efforts. These are the muse of a robust COB program.

So let’s speak about one particularly, employer outreach or employment verification. That is after we confirm working standing or group measurement or complete variety of staff with an employer. This has a direct influence on primacy with Medicare and your plan. We do that due to an business hole the place employers don’t replace working standing with you, the plan, in a constant method or do not present the required working standing in any respect, particularly as IT pertains to situations corresponding to COBRA, retirement, or long-term incapacity.

Additionally, in gathering this Information from the employers, you could do IT in a means that you may have a clean expertise for each the member and your shopper on this occasion as properly. a vendor to have the ability to help these efforts, Cotiviti finds that as much as 30% of our Medicare different insurance coverage findings are a direct results of that employer outreach. IT exhibits the true worth of that investigatory-based COB answer that goes past what an asset or information file gives as properly.

Along with that, there are a large number of advanced ideas that transcend what these belongings are discovering as properly. One being automated new child protection the place enrollment would not even exist for one plan that is not accessible on these belongings and recordsdata. As well as, tertiary protection, the place a member could have three plans, together with two industrial plans in addition to Medicare, primacy for a member could change for any motive, for any particular person plan, thus leading to missed alternative or overpayments. There are additionally claim-based ideas corresponding to pre-entitlement and correct billing directions with every MAC Medicare estimation and incorrect secondary legal responsibility on identified COB situations. A complete program appears to be like in any respect of those so as to be sure that you are capturing all the chance that goes past leads.

Chris: So IT seems like after we speak about COB and a number of protection situations, there’s a whole lot of nuance and a whole lot of element that goes into these kind of critiques. So after we’re speaking about this, IT seems like that is a part of a full fee integrity answer, proper? We’re trying throughout the fee continuum and throughout declare varieties.

So we regularly see this materialize as together with automated enhancing and coverage utility in addition to evaluate of appropriate coding and scientific accuracy and even as deep as waste and abuse critiques to focus on and discover suppliers who could also be mis-billing claims. However there’s a lot nuance, Evan, in sort of the way you describe the COB world and what goes into a few of these critiques and the way the plans must strategy these claims and the billing accuracy from completely different angles for COB. So what would we anticipate to see—payers leveraging information belongings and inner groups that we talked about—what are a few of the different items of the puzzle {that a} plan must be in search of when IT involves COB accuracy particularly?

Evan: We do anticipate our plans to start help of a COB program by means of these entitlement belongings and possibly even a industrial different insurance coverage asset as properly too—that is anticipated, however let’s additionally speak about some options that may exist in parallel with these as properly.

So let’s begin with prepay. Ask your self why your prepay enhancing would not embrace coordination of advantages both as a major editor internally or in addition to a secondary editor. Cotiviti’s prepay COB answer can seize as much as 25% of complete program financial savings in prepay, ranging anyplace from Medicare and industrial different insurance coverage and new discovery to incorrect calculations. That is distinctive to information belongings as a claim-based intervention, as IT helps prioritize membership on the proper time. Looking for a vendor to carry out professional validation regardless of the intervention level is required to maximise your plan worth.

A prepay answer can be important as a result of pace is important in coordination of advantages. Figuring out COB situations creates price avoidance, including elevated worth to your plan and figuring out these overpayments sooner than a postpay answer. And in partnership to prepay, you want a strong postpay program to seize all of the situations that we spoke about beforehand. COB, the idea, could also be at occasions easy and as much as little interpretation, however as a result of fixed modifications your members expertise and the investigatory nature of COB, a robust postpay program with thorough member-centric processes to help with monitoring your membership, to intervene on the proper time, helps make a program complete.

Chris: Working throughout the continuum is important, so what we imply by that’s each pre and postpay. So what are a few of the issues, Evan, that you simply really feel that plans must be in search of from a vendor particularly who can carry out in each areas, each pre and postpay?

Evan: Like we mentioned, you are in search of consultants and also you’re in search of an answer, so that you needn’t handle so many various processes, factors of contact, and capabilities throughout your COB answer. First, you are searching for COB consultants with a robust understanding of MSP, NAIC tips, and state interpretation. Additionally interpretation of explanations of advantages (EOBs), plan language, and abstract plan descriptions, and extra. You are additionally searching for a workforce that may scale to your wants in supporting employer and supplier outreach on the proper time, figuring out new and sophisticated COB situations that transcend the info belongings we mentioned. This vendor must be a full answer and supply the breadth and depth wanted to maximise your plan worth. Many plans and distributors could also be assured of their strategy for simply half the image as properly, and sometimes that is Medicare different insurance coverage, however you want consultants throughout each Medicare and industrial different insurance coverage.

Of Cotiviti’s findings, roughly 50% of our financial savings is when a industrial different insurance coverage is major. It’s essential to ask your self in the event you’re maximizing your worth on this area. You additionally want a associate to help in all the pieces past coordination of advantages, together with all issues restoration. That is issues corresponding to dispute evaluate, lettering, handbook collections—all the pieces assortment and supplier help. You additionally want a service, somebody that may present you documentation and interpretation for brand new ideas and alternatives, customer support, in addition to reporting. All these duties being supported by a vendor permits your inner workforce to deal with producing extra financial savings and worth and offer you confidence that you simply’re maximizing what you may in your program.

Chris: We see payers come to us with numerous setups from their inner perspective, so we see them with growing inner groups to groups which might be fully constructed out with some background COB experience in-house already. And we additionally see some who come to us with a number of outdoors distributors within the COB area. Do you see any extra worth to having a number of distributors work that coordination of advantages in numerous previous place configurations as properly?

Evan: Completely. We see a number of completely different configuration factors in COB. First, I’d take into account a vendor that may help you throughout the fee continuum, particularly searching for help and prepay. From there, there’s worth in a vendor stack to make sure you’re capturing all alternative wanted in postpay as properly too. At Cotiviti, we’ve got expertise in each first- and second-pass positions throughout numerous plans. For one plan, particularly, a big plan, regardless of being a second-pass vendor and that plan leveraging a number of completely different information belongings, we nonetheless make up roughly 30% of the entire general COB financial savings—proof that professional evaluate and a full service is important to your program to make sure that you are maximizing the worth.

Chris: Thanks Evan. That is a very nice rationalization of a few of the complexity of COB and a few of the causes that plans may wish to have a number of and completely different intervention factors, together with probably completely different and a number of distributors stacked in postpay. There’s clearly a necessity for supplemental information sources and high quality information, and naturally that human component that may apply these guidelines and the way that experience is so important. So after we put that each one collectively, IT seems like a great COB program is perhaps considerably distinctive to every plan, however typically, there are consistencies in what we see as needed.

We absolutely anticipate plans to leverage an inner COB workforce; usually that is the primary line of protection. We see plans ingest information belongings corresponding to CAQH and membership and entitlement information to assist complement these critiques. After which we see plans use the capabilities and experience of a full-service COB vendor to assist span that hole between pre and postpay to make sure that these are working from each ends of the fee spectrum, together with that validated identification of overpayments, that full-service high quality vendor appears to be like at all the pieces, together with supplier help, employer outreach, restoration work, throughout offsets and assortment work as properly.

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