Janetta Dean

Janetta Dean has more than 17 years of experience in payment integrity with expertise in Coordination of Benefits (COB). At Discovery Health Partners, Janetta is responsible for managing Payment Integrity solutions as our Manager of Eligibility Programs.

4 ways technology is shaping the future of COB

When we think of the future, we tend to think of things like space travel, the next presidential election, and what we’ll have for dinner later tonight. That’s all very interesting, but what about the future of…healthcare coordination of benefits? Okay, maybe it’s not as exciting as humans living on Mars or Oprah for president, but there are some interesting things happening in COB that are changing the way health plans approach this age-old process. Here are four ways technology is changing how we think about COB.

1. A data-driven approach

What do we mean by a data-driven approach? At the most basic, it means to use all relevant and available data sources to identify members with other insurance who could have recoverable claims. This isn’t necessarily futuristic. Don’t we all use multiple sources for this now – eligibility and claims files, MSP files, CAQH data, State Medicaid files, Section 111 reporting?

For the most part, yes. But HOW are we looking at this data? Is it a team of investigators pouring over Excel spreadsheets and printed files, trying to draw conclusions? Do they waste a lot of time investigating claims that aren’t recoverable? Are they calling members to get the information they need? Do they miss potential opportunities to recover claims?

It’s not just a matter of having the data. What matters as well is the speed with which we’re able to get that data. As an industry, when we think about the future of COB, we need to think about fast, automated data integration across multiple sources. In other words, bringing all that data together into a single database that can be queried to quickly and accurately identify claims that are likely to be another provider’s responsibility (see #2 below).

We need to think about refreshing this data faster so we have the latest information at our fingertips at all times so we can make decisions earlier in the process that would allow us to maximize our recoveries and up-front cost avoidance. And we need to think about emerging data sources that can help improve the accuracy of the member profile. For example, is there an opportunity to mine social data (e.g. Facebbook posts) to learn of qualifying life events?

If you really want to get into the weeds about data integration in the health insurance industry, check out this great blog post by data integration company Veristorm.

2. Analytic focus

Wikipedia defines analytics as the “discovery, interpretation, and communication of meaningful patterns in data.” From a COB perspective, we can apply analytics to the data we have to identify members with the highest probability of having other coverage.

Most in the industry are at least dipping their toes into the analytics pool. Much of it today is “rules-based” analytics. For example, we’ll create a simple business rule that says when a member turns 65, they should be on Medicare. This yields information that tells us to analyze whether those members are on Medicare.

Analytics is where things could get really interesting for COB and despite much hype, the industry is just getting started here. When we apply advanced analytic techniques like predictive analytics, we can quickly look at multiple factors (such as age, demographics, disease categories, and much more) to more closely pinpoint members that may require COB. Taking it a step further, machine learning technologies would automatically determine the most successful indicators (or combination of indicators) of other coverage and automatically update the analytic models to reflect that learning.

Even to me, this all sounds very complicated and daunting. Take it from my colleague Steve Forcash, Discovery’s analytics expert, who recently said, “For most organizations, leveraging analytics to drive improvements in payment integrity is more of an evolution than a revolution. I suggest starting small.” For example, start with your internal claims and eligibility data and see what you can glean from that. Find out what works and build on it from there. There are several benefits to advancing the use of analytics in healthcare COB, including:

  • Reducing the cost of COB (less manual effort, less time investigating false positives)
  • Reducing member abrasion (more accurate identification means less validation work)
  • Increasing cost avoidance (denying claims that are another plan’s responsibility)

3. Case management application

Full disclosure: this point is somewhat self-serving because Discovery has a proprietary case management application that we use to deliver COB solutions for our clients. But I feel so strongly that this current capability is also critical for the future of COB, that I couldn’t leave it out.

Though COB is a seasoned, well-oiled machine for most health plans, it does encompass many steps and individual processes. It also demands a “paper trail” to capture all the information that is discovered throughout those processes. A case management application is the perfect way to guide your team through your specific process, while capturing and sharing critical data along the way.

This single data repository should be used to drive all case-related activity so you have fast access to high-level and detailed case data. Our Discovery Case Manager allows you to see activity history, planned activity (case diary), and notes (about investigations, status, phone calls, etc.). You also can identify and manage rebill activity at the provider and claim level, and store and update employer and other insurance information and payer order.

Having all this detail in one place provides you with the digital paper trail that not only supports your recovery work, but that could also allow you to make future claims payment decisions more quickly and accurately. And this brings us to our final point below.

4. Reporting tools

As COB organizations become more sophisticated about their use of data and analytics, their reporting capabilities will improve. Dashboards and reports can be automatically created based on data in your case management tool and/or analytic tools to provide you with easy-to- see information about your membership, COB opportunities, and results.

Having access to more accurate data, the organization will be able to better identify members with potential other insurance, improve the accuracy of forecasting, and analyze trends. Reporting functionality through dashboards and/or standard reports is critical for understanding how well your COB process is functioning and to identify areas for improvement. Even with limited data and analytic capabilities, you can begin to experiment with reports. Important data to track for COB includes:

  • Case inventory
  • Case pending
  • Case status
  • Recoveries

The bottom line is that, wherever your COB program is in terms of technology maturity, there may be opportunities to step that up and boost the performance of your program even further. Most COB programs struggle with issues such as ongoing eligibility/member status errors, member and provider abrasion, and resource constraints. Technology-enabled COB can help address these and other challenges that may be standing in the way of your best year yet!

Learn about more COB trends in the infographic, Five trends in healthcare Coordination of Benefits.

Janetta Dean4 ways technology is shaping the future of COB
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4 integration points to keep in mind with your COB vendor

 

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.

For more information about COB, please visit our resources page.

 

 

Janetta Dean4 integration points to keep in mind with your COB vendor
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