Coordinating benefits in today’s healthcare environment is as much a challenge as it is a necessity. Coordination of benefits (COB), or third-party liability (TPL), has implications beyond cost containment, as it also enables the proper coordination of care for those with access to multiple sources of coverage. On a broader scale, these processes help maintain the integrity of the healthcare safety net by ensuring Medicaid remains the payer of last resort.
To address this broad scope, today’s COB must be equally comprehensive. By prioritizing these five elements, healthcare organizations can ensure their COB functions are optimized across the key areas of performance, compliance and value.
1. Big Data
COB relies on having access to current and comprehensive coverage information across all plan types, which may include medical, behavioral, pharmacy, vision and various others. This requires an extremely wide lens beyond what claims data alone can provide. Solutions that draw on a vast network of third-party liability data across a diversity of payers and third-party organizations are best equipped to maximize COB through stronger analytics capabilities, better match rates and overall accuracy.
2. Investment in Innovation & Continuous Improvement
Consistently evaluating systems and identifying areas where technology could potentially streamline processes is a key element of an effective COB program. Robotic process automation, for instance, can help maximize resources at both the payer and provider level, freeing up staff to address more pressing issues within the organization. Artificial intelligence and machine learning can also be powerful process efficiency tools; for example, developing algorithms that identify and adjust select claims prior to submission can lessen the heavy rework associated with denials.
As healthcare changes rapidly given the current global pandemic, assessing the viability of current systems and pinpointing opportunities for process improvement is especially important. Implementing pre-payment solutions, transitioning to electronic billing for reclamation claims and being adaptable to inevitable change can help payers maintain the effectiveness of their COB programs without fueling burnout.
3. Customized Business Rules Accounting for Submarket Nuances
With ever-changing regulations and increasing oversight from state and federal agencies, healthcare organizations must ensure their COB programs are equipped to maintain compliance. This not only requires a deep and evolving understanding of regulatory nuances across states and populations, but also a technology infrastructure that allows for the configuration of business rules. Keeping a close pulse on things like dual-eligible policies, pharmacy carve outs and state-by-state disallowance and recovery rules — and being able to quickly adapt to these oft-changing guidelines — is essential in today’s shifting landscape.
4. A Comprehensive TPL Strategy
There are several reasons an individual may have access to multiple sources of health coverage, adding layers of complexity to COB. In addition to uncovering all available health benefits, potentially liable non-healthcare payers must also be taken into account. A claim resulting from an accident or injury, for example, may be the responsibility of a casualty or workers’ compensation plan; however, these scenarios tend to be high cost and high complexity, requiring specialized expertise to navigate the identification and recovery process.
5. A COB Thought Partner
The complex and data-driven nature of today’s COB requires an evolution in technology, ideology and practice to overcome limitations of traditional processes and optimize systems for the future. In a recent white paper, thought leaders at HMS outline a number of COB innovations driving sustainable value for healthcare payers, providers and consumers. Download the white paper here.