It’s common for health plans to manage their coordination of benefits programs internally while using one or more external vendors to provide supplemental COB as a safety net. These vendors come in after the health plan’s COB process to find any missed recovery opportunities.
When selecting a COB vendor, health plans are most interested in partnering with experts whose solutions deliver considerable incremental recovery opportunities with minimal disruption to their existing operations. In fact, the most common question asked by the health plan is, “How will this supplemental solution be integrated into our existing processes?” They want to know that the supplemental process won’t interfere with or duplicate their own work.
As health plans engage with external vendors for supplemental COB, here are the most common integration points of alignment between supplemental COB and health plan operations.
- Vendor and health plan communications—This integration point is the announcement of the partnership between the health plan and the selected COB vendor. The health plan will provide written communication explaining services being provided by the COB vendor to internal departments (e.g., member services, provider inquiry, and claims billing) along with information from the COB vendor such as a FAQ reference sheet.
- Insurance investigation and verification—This integration point is the most important for minimizing member abrasion. The COB vendor and health plan partner together to customize member Informational Questionnaires (IQ) mail correspondences sent by the vendor. In most cases, the agreed-upon customizations may include adding the health plan’s logo, plan-specific language, and taglines. The COB vendor also should coordinate their member IQ mailings around any of the health plan’s member mailings to avoid members receiving multiple mailings at one time. In addition, the COB vendor should attempt to verify all other health insurance leads by contacting other health plans by phone or using eligibility verification web portals to validate other health plan coverage, rather than reaching out to the member directly.
- COB pursuits—This integration point defines the guidelines by which the COB vendor must abide when providing supplemental COB services to the health plan. The identified guidelines at this point may include items such as COB exclusions (e.g., membership, plan, or group) and claims under internal COB investigation. The more specific the guidelines are, the lower the chance for the vendor and the health plan to duplicate efforts.
- COB claim recoveries—This integration point outlines the COB claim recovery process between the COB vendor and the health plan. The finalized recovery process should include the following: frequency of claim recovery file submissions being sent to the health plan, the health plan claim approval/denial terms, and method(s) by which either the vendor or the health plan recovers COB over payments from the provider.
Before health plans engage with an external vendor to provide additional COB services beyond internal COB efforts, it is important to discuss and document integration points and potential points of conflict within each of these areas.
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