eBook: The modern guide to COB

eBook: The modern guide to COB

Manual and error-prone Coordination of Benefits processes contribute to millions of dollars in annual waste

Save time, resources, and paper with advanced technologies that can help you transition from cost recovery to cost avoidance.

Download our eBook and see how a modern COB approach can help you:

  • Increase recoveries
  • Improve cost avoidance
  • Reduce administrative costs
  • Achieve greater member and provider satisfaction

Discovery Health PartnerseBook: The modern guide to COB
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Maximizing your COB processes with integrated technology

Primacy and eligibility errors can lead to serious losses and expenses. By some estimates, a third of paid health claims contain errors, and as many as 15% of members have other insurance—representing a staggering $1 trillion in annual waste1. Paying for claims due to incomplete or inaccurate member eligibility not only costs your plan millions in higher payouts and administrative costs, these errors can also generate substantial downstream administrative costs and greatly impact your provider and member relationships.

While Coordination of Benefits (COB) is a common occurrence (the process of determining which plan pays for what portions of a claim), the challenges associated with addressing other insurance retrospectively lead to increased administrative costs and payouts. Plans must go beyond the traditional process of post-payment recovery to an expansion of prospective processes that identify potential primacy conflicts while still in the pre-payment stage.

Things to ask as you evaluate your COB processes:

  • How can we identify more instances of other coverage and maximize our savings from cost avoidance and recovery of overpaid claims?
  • Do we have the data mining technology and expertise to identify Medicare or other commercial coverage?
  • How do our COB processes compare to industry best practices?
  • How do we transition our COB program from recovery to cost avoidance?
  • How can we minimize member and provider abrasion while coordinating benefits?

Data mining, business intelligence, and analytics are at the core of today’s most successful payment integrity strategies, including COB. As part of our connected payment integrity approach, Discovery’s COB solution automates data integration across multiple sources, bringing it all together in a single database that allows for quick and accurate identification of claims and provider responsibility. This means frequently refreshed data with up-to-date information. In addition, predictive analytics and machine-learning technologies analyze and prioritize data, allowing us to flag and take a closer look at members with a high probability of having other coverage. Our goal is to identify and address primacy issues at the earliest possible stage—improving claims payment accuracy, building stronger relationships with providers, and reducing administrative expenses.

To learn how Discovery Health Partners has helped health plans drive cost savings and millions of dollars in recoveries, download our COB case study or visit our Coordination of Benefits solution page.

1 The Office of the Actuary in the Centers for Medicare & Medicaid Services (July 2015)
Ron JonesMaximizing your COB processes with integrated technology
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Case study: Coordination of Benefits (COB) for healthcare payers

Case study: Healthcare Coordination of Benefits (COB)

COB solution drives measurable cost savings and millions of dollars in recoveries for three health plans

As these three cases demonstrate, the Discovery Coordination of Benefits solution was designed specifically to address critical COB challenges, with an emphasis on flexible delivery models that support our clients’ unique requirements.

Harnessing the power of our Healthcare Analytics Platform, our COB solution enables fast and accurate identification, investigation, case management, dashboards, and analytics, as well as insourced or outsourced delivery.

Download this insightful case study today.

Discovery Health PartnersCase study: Coordination of Benefits (COB) for healthcare payers
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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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Calculating 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.

Making the business case for prepayment cost avoidance

As health plans more aggressively adopt cost avoidance as a payment integrity tactic, many struggle with the business justification. There simply is no industry-standard method of quantifying cost avoidance.

With pay-and-chase models of recovery, it’s usually pretty simple – you calculate the recovery and if you’re using a vendor, you subtract a percentage contingency fee. It works nicely in a spreadsheet formula and the extra cash looks great in your P&L. But if you’re avoiding—not recovering—dollars, how do you measure the return on investment? How do you calculate the costs avoided?

Health plans have been left to their own devices to determine the right method to quantify the business case for cost avoidance. And to compound this issue, the method of measuring cost avoidance and the business case isn’t consistent across all types of payment integrity. The calculation and return on investment will differ depending on whether you’re looking at coordination of benefits, subrogation, claims analytics, etc. Based on my experience, even among the largest health plans, there is incredible diversity of opinion on how to measure and value prepay. Read on to learn about some examples that I’ve come across.

Claims cost multiplied by estimated months of savings

This large commercial plan with over 40 million members uses average claim cost per member to calculate potential savings from cost avoidance. The plan first identified “leads,” or members suspected of having other coverage, and sent them to Discovery Health Partners to verify other coverage.

Of those leads, 10% have been confirmed to have other primary coverage. The plan estimates that it would have paid claims for those members for 6 months before catching the error. By multiplying the 6 months times a monthly claims cost per member, the plan figures it avoids more than $7 million in erroneous payments.

This method provides a general sense of the value of cost avoidance, which allows this plan to justify the cost of using a vendor as a partner for some of its prospective COB processes. Not all buy into this method, though. Some might argue that not all members would incur the average claim cost in all 6 months, and some of the costs, had they been paid up front, likely would have been recovered on the back end. This method doesn’t account for that.

On the other hand, it accounts for neither the administrative cost avoided by not having to recover on the back end nor the fact that a percentage of recovery efforts are unsuccessful. In the end, this plan felt that these balance each other out and the methodology works for now.

In another example for COB cost avoidance, one of our clients uses the average cost of claims for each member over the previous 12 months and applies that value over the next 12 months.

Costs to consider when calculating ROI on cost avoidance

Once you have identified a method of calculating the value of cost avoidance, you need to understand the costs that are involved in developing cost avoidance capabilities.

  • Vendor fees. How vendors make revenue will depend on the method the health plan uses to calculate cost avoidance. Options could include contingency, transactional (per validation), monthly, and fixed fees.
  • Resources. Subject matter expertise and operational expertise will help ensure you avoid the right costs at the right time with minimal member and provider abrasion.
  • Technology. Software and other programs allow you to integrate the data from correct sources into your systems so you can make timely pre-payment decisions. This could include applications to manage the workstream.

The move to prepay cost avoidance requires a set of skills that health plans need to develop or acquire in order to be successful. These should be considered when calculating the cost. See our infographic for a list of these capabilities.

 

 

 

 

 

 

 

 

Discovery Health PartnersCalculating cost avoidance: A closer look at one of 2017’s top payment integrity trends
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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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Discovery Health Partners announces webinar on trends in COB

A changing environment drives the reevaluation of current Coordination of Benefits practices

 

ITASCA, IL (April 17, 2017) –Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, will host a webinar April 25, 2017, exploring the impact of changes in technology, information management, and best practices on Coordination of Benefits (COB). Titled “Coordination of Benefits: How the latest trends are impacting your plan,” the webinar features Discovery healthcare payment integrity experts Paul Vosters, President, and Kathy Cortez, VP of Operations.

During the webinar, the team will explore several trends that are changing the way health plans look at their COB functions and how plans can respond to improve plan performance. Attendees will learn about:

  • Growing complexity of managing member eligibility status and why it makes COB more challenging than most realize
  • Interest in prepay cost avoidance and how this road so paved with good intentions also has hidden landmines
  • The push to use data matching services to validate member eligibility
  • Increased focus on minimizing member abrasion in the COB process
  • New paths to improved data integration and automation and overcoming obstacles in the COB process

Seats remain available for this free webinar, which already has 125+ participants. To register, visit Discovery’s COB webinar page, where one can also sign up to review the webinar on demand at a later time.

 

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience.  We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.  More information about our solutions, including Coordination of BenefitsEligibilityMedicare Secondary Payer Validation and Subrogation is available at www.discoveryhealthpartners.com.

 

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Discovery Health PartnersDiscovery Health Partners announces webinar on trends in COB
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