eBook: Setting up for coordination of benefits (COB) success

A robust coordination of benefits (COB) program can be one of the most difficult elements for health plans to achieve in creating a stronger payment integrity strategy. As rising healthcare costs, increasing medical loss ratios (MLR), and the need to maintain member and employer satisfaction grow, COB can be an area of substantial savings and operational efficiency. Determining the correct order of benefits swiftly, accurately, and comprehensively can help plans in a number of ways: avoiding increased medical expenses, reducing administrative burden, and decreasing member dissatisfaction and provider abrasion.

Yet many COB programs lack the necessary data, analytics, business rules, and , and time to maximize savings and avoidance. This leads some health plans to default to managing COB internally with limited resources and expertise, often missing out on the full potential of what a comprehensive COB program can deliver.

An end-to-end COB program that goes beyond just entitlement data is essential. Leveraging accurate data, advanced analytics, and specialized expertise provides a clear path to achieving a high-value COB program.

Take a look at some of the ways data alone can be improved in your COB strategy.

Sourcing the right data

Effective COB begins with sourcing the right data and supplementing it with additional sources such as contracts, eligibility files, third-party benefits agreements, and more. Relying solely on entitlement data is insufficient, as entitlement data often lacks the depth and breadth required to paint a complete picture of a member’s benefits landscape. Entitlement data can also be prone to inaccurate or outdated information. To overcome this, health plans must source data from multiple channels, such as:

• Eligibility and entitlement:Going beyond gathering eligibility and entitlement to build an appropriate history to better track COB over time.
• Employment records:Understanding the accuracy and comprehensiveness of the employment status data received, and documenting gaps within groups.
• Additional data sources:Creating a comprehensive picture with provider records, claims history, and member-reported information.

Executing data enrichment

Once the right data is sourced, the next step is enriching that data to maximize potential opportunity. Because this data is leveraged from multiple disparate sources which come with their own complexities, it is important to fill in the gaps. For COB, this can include:

• Documenting enrollment across a full family plan, including full eligibility history and other known coverages.
• Identifying and correcting potential gaps in demographic information, such as incorrect or invalid addresses, names, etc.
• Creating a group history of the member to track working history and identify potential changes in primacy faster; enriching that information with a comprehensive, low-abrasion outreach program when applicable.
• Tracking claims history for indications of potential other plan enrollment, disability, or end-stage renal disease (ESRD) entitlement to prioritize selections.

Investing in COB

Health plans should look at COB across the payment continuum, adding COB editing to existing prepay programs, ensuring responsibility for paying the claim in the first place, while continuing to build on an already strong postpay program. By continuing to shift, plans are reducing administrative costs to manage COB while maximizing savings and avoidance. Navigating COB with accurate data, advanced analytics, and expert guidance can help plans achieve significant savings, improve operational efficiency, and maintain a smooth, non-abrasive experience for members and provider partners.