Choosing the right COB partner for your plan

At any given time, between 8-15% of a health plan’s membership is covered by another plan, resulting in incorrect eligibility information that could be costing your plan millions in incorrect payments, time, and resources.

Disparate data, siloed information systems, and multiple moving parts all contribute to incorrect eligibility information and improper payments. To identify instances of other health insurance, your plan needs access to multiple data sources and the ability to verify state, CMS, and CAQH data—all of which add more time and resources. Even if done correctly, there is still a chance your plan is leaving money on the table. So what can you do and how do you find the right partner to supplement your team?

Choosing the right partner has never been more important or more daunting. A growing number of vendors claim to use leading-edge technology such as data mining, artificial intelligence, and machine learning. But what does this mean to you and your health plan?

To help you choose the right COB partner, here are some key factors to consider:

  • Data: Where is the potential vendor getting its data and is the data relevant to your plan?
  • Expertise: What type of clients does the COB vendor work with today? Are they specialized in one line of business or do they work across multiple? Does the vendor have folks with plan-side experience?
  • Satisfaction: Does the vendor have a track record of delivering value to its clients?
  • Flexibility: Is the vendor flexible enough to wrap around your current team? Or are they inflexible to change?
  • Technology: Is the vendor using cutting-edge technology—like AI and machine learning—to look at eligibility more holistically?
  • Research and development: Is the vendor relying on standardized practices that “worked before”? Or do they have a team of seasoned research analysts dedicated to looking for new rules, regulations, data sources, and data points to deliver additional value?
  • Full-service capabilities: Does the vendor offer solutions spanning all phases of the claims lifecycle (e.g., prospective, retrospective, hospice, etc.)?
  • Security: Is the vendor HIPAA and HITRUST compliant? What security standards and access policies are in place?
  • Partnership: Is the vendor willing to learn about your organization, what’s important you, and how to support your COB process and goals? Is this a joint collaboration and journey? Where does you plan line up with the vendor’s other clients? Will you be a priority for them?

 

To learn how Discovery Health Partners can help support your COB initiatives, visit our Coordination of Benefits solution page or open up the contact form to the right.

Kevin McDonaldChoosing the right COB partner for your plan
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White paper: Proactive COB strategies

White paper: Proactive COB strategies

Cost avoidance is more than just a way for Medicare Advantage plans to improve their bottom line; it gives them a competitive edge in a crowded market.

Even as recovery operations continue to thrive, health plans have sharpened their focus on prepayment technologies that can manage costs, optimize claims payments and ensure the care patients need is appropriately covered. As health plans invest in a technology driven approach that incorporates new, more robust data sources into their COB processes, they must find the right balance of recovery and a proactive approach that looks to solve root cause of incorrect payments that result from incomplete or inaccurate coverage information.

To stay competitive and meet consumer needs, Medicare Advantage plans may need to offer low-cost supplemental benefits that help them attract new members. A proactive COB strategy that addresses primacy order and eligibility can provide the means to fund these additional offerings.

Fill out the form to download this informative whitepaper today.

Discovery Health PartnersWhite paper: Proactive COB strategies
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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. 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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Video: Drive stronger results with technology-enabled COB

Drive stronger results with technology-enabled COB

A technology-enabled approach to Coordination of Benefits can help identify additional opportunities to save and recover while minimizing member and provider abrasion

For more information

Please visit our Coordination of Benefits page or open the contact tab on the right to get in touch with a Business Development Associate.

Chelsea GerschVideo: Drive stronger results with technology-enabled 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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Prepayment cost avoidance: A closer look at one of 2017’s top payment integrity trends

 

This post is part of an ongoing series about trends happening within the payment integrity space for healthcare payers. This series features contributions from Discovery Health Partners payment integrity experts discussing these trends, why they’re happening, and how they affect health plans. To learn more about all of the top trends, download our 2017 Payment Integrity Trends whitepaper.

Health plans see value in prepayment cost avoidance

Health plans are making a concerted effort to focus more of their payment integrity resources on avoiding inaccurate claims payments up front, rather than recovering erroneous payments on the back end. There is general agreement that this creates more value for a plan. When done successfully, prepayment cost avoidance allows the plan to avoid 100% of the claim cost (vs. the portion they can recover) and it reduces downstream administrative costs associated with recovery. I think we all can agree that having to work a claim multiple times is obviously more expensive than having to work it once.

In addition to financial benefits, prepayment cost avoidance can help health plans positively affect relationships with providers by reducing the burden on them to rework claims that are the responsibility of another payer. I recently saw a statistic that said providers incur an additional 20% – 30% of the cost of any claim they have to rework. Your providers would welcome a reduction in that cost.

Meanwhile, a focus on cost avoidance makes your members more accountable for ensuring that correct eligibility information is on file. Particularly in an area like coordination of benefits, members should feel more compelled to be proactive about providing the health plan with accurate, current information so their claims will be paid promptly without fuss.

Why the cost avoidance shift is happening now

In my experience, this is probably the biggest trend in the industry today. Why? Because of the vendor fees and administrative costs associated with recovering a claim that was paid incorrectly. At a time when health plans are very focused on reducing administrative costs and managing shrinking margins, executives are paying attention to every source of leakage.

While prepayment cost avoidance is not a new concept by any means, it requires a level of maturity within a health plan’s payment integrity operations that some plans are just now reaching. For one thing, more mature health plans typically have stronger data integration and analytics capabilities that allow them to look across multiple sources of information to make more accurate payment decisions quickly.

At the same time, their experience with postpayment recovery operations has given them some data to build a business case for the shift to cost avoidance. In my opinion, the largest barrier to cost avoidance until now has been the inability to justify the effort—cost, resources, technology, and vendors—in terms of a business case. There is no standard ROI or business model to work with, and every plan I’ve talked to uses a different approach. The fact is that health plans need to spend money to create a prepay cost avoidance capability and that means making sure the right people in the organization understand the value and business case for it.

For more information, see our infographic about capabilities required for successful prepay cost avoidance.

Coexistence with postpayment recovery

While prepay cost avoidance should be part of a plan’s payment integrity strategy, postpayment recovery must remain part of that strategy as well. The ability to make a prepayment decision can be hindered by the availability of information and the dynamic nature of eligibility and primacy information. Information often isn’t available fast enough to decide if a claim should be held or pended, so prompt-pay rules dictate that the plan must pay.

Meanwhile, member eligibility status and primacy are moving targets and constantly change, so payments are based on outdated information. For some payment integrity functions, like subrogation, costs can be avoided only on part of the whole recovery. In that case, only the first-party liability costs can be avoided, while third-party liability costs have to be paid.

Finding the right balance for your plan

In our view at Discovery, prepay cost avoidance and postpay recovery have to coexist as an integrated solution so you can follow the transaction through the whole lifecycle. The goal should be to find the right balance for your organization.

As health plans consider the proper balance of prepayment cost avoidance and postpayment recovery across their payment integrity programs, it’s important to remember that this is largely a cultural decision. A plan has to be ready to adopt prepay solutions, and a lot goes into that decision—including regulatory issues, technology capabilities, data availability, subject matter expertise, and the business case.

 

 

Discovery Health PartnersPrepayment cost avoidance: A closer look at one of 2017’s top payment integrity trends
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Webinar: 2017 Trends in healthcare payment integrity

2017 Trends in healthcare payment integrity

The 8 trends impacting payment integrity in 2017

Managing costs is the fundamental challenge facing all health plans today, and payment integrity is at the heart of this issue.

In this exclusive webinar on demand, payment integrity experts Paul Vosters and David Grice discuss the eight major payment integrity trends that have emerged in 2017 and offer recommendations for health plans that want to capitalize on those trends.

Please use the quick form on the right to view the webinar on demand today.

Discovery Health PartnersWebinar: 2017 Trends in healthcare payment integrity
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White paper: 8 Payment integrity trends to watch in 2017

Whitepaper: 8 Payment integrity trends to watch in 2017

Health plans’ focus on cost reduction drives fresh look at payment integrity

Discovery Health Partners estimates that for healthcare payers, payment integrity problems cost 3-7 percent of their paid claim dollars every year. That means, for example, a 500,000-member health plan with costs averaging $3,600 per member per year will pay $1.8 billion in claims, of which $54-$126 million will be wasted expense.

Based on our work with more than 60 payment integrity clients and discussions with nearly three times as many prospects, we have documented eight trends worth watching in the next year.

Download this informative whitepaper today.

Discovery Health PartnersWhite paper: 8 Payment integrity trends to watch in 2017
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Trends in healthcare coordination of benefits

A changing environment drives the reevaluation of current COB practices

 

Healthcare coordination of benefits (COB) has been a relatively unchanged process in health plans for many years, but advances in data management, analytics, cloud-based software, and digital communications are causing some interesting trends to take shape in the COB world.  These technologies, which have transformed many industries, are making their way into payment integrity processes, where health plan executives are working to address the challenges that cause inaccurate claims payments and to improve the processes that are used to identify, avoid, and recover those payments.

Inaccurate member eligibility and primacy data is often at the heart of payment issues. In fact, with multiple people and processes responsible for updating member status, it’s no wonder we don’t see more payment problems than we do. Too often, member eligibility and primacy are updated based on the narrow lens of a single person or process at a single point in time. Trying to avoid or recover claims based on this data often puts members and providers in the middle, causing abrasion and dissatisfaction. And as we know all too well, member abrasion can directly impact a health plan’s bottom line with members opting for different plans and affecting Star Ratings for Medicare Advantage plans.

As cost continues to be a core issue for health plans, it’s time to look at better ways of controlling costs, correcting payment errors, and protecting premium revenue while shielding members and providers from the fallout. Five key trends – or potential trends – are recurring topics of discussion, research, and tests among health plans and their vendors.  We recently discussed these trends in a webinar that you can watch on demand, “Coordination of benefits: how the latest trends are impacting your plan.”  The trends discussed include:

  • Momentum away from pay and pursue: As payers mature in their overall payment integrity technologies and best practices, they are working to shift more of their COB efforts to avoiding inaccurate claim payments vs. recovering them on the back end. Pre-pay cost avoidance can yield a 40% increase over recovery, so the business case speaks for itself. However, this more proactive approach requires more sophistication in areas of data integration and analytics to quickly and accurately identify claims that are not the plan’s responsibility.
  • Emergence of “matching” services: There seems to be a push among large health plans to require vendors and other health plans to leverage data matching vendors for eligibility validation. We find that this data is most useful for identifying “leads,” or potential cases of other insurance that can be further investigated. Plans can then focus their COB resources more intelligently for a better return on their efforts.
  • Attempts at using analytics: Our industry has a growing appetite to incorporate analytics into COB processes to identify members with the highest probability of other coverage.  Increasing the use of analytics throughout payment integrity generates many potential benefits, including reduced cost of COB and reduced member abrasion. While many health plans are making small steps in this area, there is still a long way to go.  Rules-based analytics can tell us, for example, that a member who is 65 should be on Medicare and we should investigate whether that is the case. But beyond that, predictive analytics and machine learning technologies can help us look at multiple factors (age, demographics, and disease categories) to more closely pinpoint members that may require COB.
  • Balancing COB efforts with risk of member and provider abrasion: Health plans are demonstrating increased frustration with traditional methods of member and provider outreach, which can result in abrasion. As a result, plans and their vendors are looking at new ways to get the information they need while communicating with constituencies on their terms. This may include using a combination of traditional communication channels as well a member and provider portals, mobility, and automation (such as using 270/271 transactions) to exchange information in more productive, cost-effective ways.
  • The need for data integration is outpacing the industry’s ability to provide it: The trend here is simply that the industry is not evolving fast enough to meet the data needs of all parties involved. Bringing together data from a variety of sources, including claims, social media, Section 111, CMS, states, providers, and much more, is necessary to support areas of eligibility, analytics, and pre-pay cost avoidance. But as an industry, we are still largely unable to sustain the high volumes of data, integrate it properly, ensure its accuracy, and access it fast enough to inform payment decisions.

To learn more about these trends and some ideas for moving forward, listen to our on-demand webinar. You can access the webinar from our web site.

Kathleen CortezTrends in healthcare coordination of benefits
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Webinar: The latest trends in healthcare Coordination of Benefits (COB)

The latest trends in healthcare Coordination of Benefits (COB)

How are the latest COB trends impacting your plan?

Discovery Health Partners payment integrity experts discuss the benefits and challenges of today’s COB trends. In this free webinar, we’ll discuss:

  • Why the complexity of member eligibility status makes COB more challenging than most realize
  • How the road to pre-pay cost avoidance is paved with good intentions and hidden landmines
  • The push to use data matching services to validate member eligibility
  • Ideas to minimize member abrasion in the COB process
  • Obstacles to improving data integration and automation in the COB process

Use the quick form on the right to view the webinar on-demand.

Discovery Health PartnersWebinar: The latest trends in healthcare Coordination of Benefits (COB)
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