Podcast: How to build a valuable coordination of benefits program

A successful coordination of benefits (COB) program can decrease medical costs, improve member relations, and avoid provider abrasion by quickly determining the correct order of benefits for even the most complex claims. But many payment integrity programs lack the necessary resources in bandwidth, data analytics, and business rules to coordinate benefit payments accurately and efficiently.

On the fourth episode of our Payment Integrity Insights podcast, Cotiviti’s coordination of benefits (COB) leaders discuss:

• The importance of having a comprehensive approach to COB to maximize value
• The differences between member-based versus claims-based strategies
• The limitations of relying solely on member eligibility data
• The strategies for optimizing COB programs, leveraging internal teams, member data, and the expertise of full-service COB partners to help ensure efficiency and savings

Don't miss this opportunity to streamline benefit coordination and prevent incorrect payments by optimizing your payment integrity program with robust data analytics and industry expertise. Stay tuned for future episodes of Payment Integrity Insights on Apple Podcasts, Spotify, and anywhere else that you get your podcasts.

Podcast guests

	Evan Okulanis Vice President, Coordination of Benefits
	Chris Ellsworth Director, Payment Integrity Growth

Podcast transcript

Chris: Here at Cotiviti we work with over 100 health plans, so we're able to take a holistic view of market trends including what we're going to be talking about today, and that's the coordination of benefits (COB) world. So let's begin by talking about some of the market environments for our health plans and how this impacts their coordination of benefits programs from top to bottom.

We see rising healthcare costs and increasing medical loss ratios, and our clients are more concerned about medical loss ratios (MLR) in 2024 than they may have been a year or two ago. As we exited the pandemic, there's a shift in cost structures from providers suffering financially, and now with increased consumption and increased costs, we see that MLR number start to increase and increased dramatically for our payers. And along with this, we also see increased administrative cost pressures building as well as competition across the health plan world as more and more payers start to enter into the environment as well.

We see payers concerned with both member and employer group satisfaction as they try to keep that business and continue to provide that quality care to their members. And there's also the provider relationships that plans need to juggle and manage. Payers need to keep providers happy to help attract those providers and retain their networks. So all of this leads to plans needing to make massively influential and important business decisions across payment integrity, but also specific to the world of coordination of benefits.

We see there are multiple vendors offering a variety of solutions. Some are software-only, some are managed solutions, and they come in at different price points and different service levels. And payers are tasked with looking for the right balance of both insourced and outsourced intervention points to help solve their problems in the coordination benefits world. So Evan, with that background and from our standpoint and our vision across the industry, what are some of the things that stand out to you when we talk about the COB pressures that plans are facing as well as some of the solutions that we see?

Evan: COB is constant. It's not something you perform just once. A member's life is constantly changing and things are happening where you can't just perform COB on the initial enrollment of a member. There are also scenarios that exist for overpayments that happen in small timeframes that yield great value. It requires a constant need to monitor your membership, and that data you require isn't always readily available in front of you.

You also need to stay current and in compliance on multiple different COB methodologies related to member with Medicare Secondary Payer (MSP) and National Association of Insurance Commissioners (NAIC) guidelines as well as state interpretation, but also claim for COB methodologies of claim adjudication and processing. In addition to that, COB is not just application of a policy—you have to source your information from somewhere. Not only do you have to source that, you have to apply that rule and perform coordination of benefits and recovery actions where applicable. With that, how do you go about confirming COB so you capture it quickly, accurately, and in a way that results in a smooth member and provider experience? Lastly, how do you have confidence you’re capturing everything for coordination of benefits?

Chris: That's interesting. From what I'm hearing, there's a lot of different moving pieces and we have clients that come in with all different types of levels of COB programs and we hear health plans say that they may be doing some piece of this internally. Why can't a plan just do this themselves? Or why can't they just choose a simpler maybe a software only option?

We see that our clients often have to answer to senior leadership on savings initiatives and numbers across payment accuracy including COB, and we're often asked to rationalize and visualize some of the use of a service vendor versus an in-house or a software-only solution. And we understand that once there's a cost line added to the equation, there's going to be more eyes watching that piece of that puzzle. So with that background in mind, we're going to be talking about some of the elements that plans need to consider in building a successful coordination of benefits program and what that value creation from auditing for other coverages looks like when a plan is working with a COB vendor.

So plans having enrollment and entitlement data either in-house or from an external data source and how that data source alone might not be enough for plans, and how they may be handcuffed by a leads-only approach to COB overpayments and payment errors that still requires research, validation, outreach, and recovery to all be performed by a limited resource. Evan, in your experience, can you talk about this a little bit more—that internal DIY data review and why that might not be enough for a full COB program value?

Evan: With the entitlement or enrollment data assets as well, those have been around for a long time, some around the past decade, but some even around for longer. There's however a trend that we're seeing more often being promoted that those data assets alone are what makes a COB program. Those assets are obviously valuable; they provide you with a good picture and a good window to begin your investigation, but as you brought up, they're just a lead. They still require a significant amount of effort to review and maintain.

But for a lot of our plans, the number of records that's available for them is insurmountable. You don't necessarily have the resources on hand to support hundreds of thousands of records to be able to maintain all of those and capture the opportunity that's needed for COB as well. In addition, the data on those assets can be incomplete or outdated or even invalid, meaning they can't be fully automated and you're expending your resources on investigations that aren't always yielding value and you're not getting to what those assets don't provide you as well.

When you tend to focus purely on the data assets for a COB program, you miss out on value. For payers we support today, we found that 40% of our commercial other insurance findings aren't even on CAQH's COB Smart file. This is important for our plans and partners to understand as just in the commercial other insurance space alone, you not only need to support investigation recovery effort on CAQH's data, but also work to manage the remainder of opportunity that exists beyond that. And that's just commercial other insurance. It doesn't even include Medicare as the other insurance as well. You need to ask how the best way to tackle that is.

Chris: So let's unpack that a little bit more and discuss that. So beyond the ability just to leverage a plan's internal data assets, what do you look at for plans to get the most out of their COB program?

Evan: A successful COB program doesn't stop with leveraging a data asset to get the full picture. Like we talked about, those files are a lot of data and they are strong leads, but they leave open a pool of opportunity within themselves, but also without it. In addition to that, data, like we talked about, is ever changing. As a member's life proceeds, things change. A life event such as a birth, a marriage, an illness may change a COB scenario and you won't be able to capture that overpayment with just leveraging an asset. So one of those circumstances that require review, first and foremost is investigation based-efforts. These are the foundation of a strong COB program.

So let's talk about one in particular, employer outreach or employment verification. This is when we verify working status or group size or total number of employees with an employer. This has a direct impact on primacy with Medicare and your plan. We do this because of an industry gap where employers do not update working status with you, the plan, in a consistent manner or don't provide the required working status at all, especially as it relates to scenarios such as COBRA, retirement, or long-term disability.

Also, in gathering this information from the employers, you need to do it in a way that you can have a smooth experience for both the member and your client in this instance as well. Looking at a vendor to be able to support those efforts, Cotiviti finds that up to 30% of our Medicare other insurance findings are a direct result of that employer outreach. It shows the true value of that investigatory-based COB solution that goes beyond what an asset or data file provides as well.

In addition to that, there are a multitude of complex concepts that go beyond what these assets are finding as well. One being automatic newborn coverage where enrollment doesn't even exist for one plan that's not available on these assets and files. In addition, tertiary coverage, where a member may have three plans, including two commercial plans as well as Medicare, primacy for a member may change for any reason, for any individual plan, thus resulting in missed opportunity or overpayments. There are also claim-based concepts such as pre-entitlement and proper billing instructions with each MAC Medicare estimation and incorrect secondary liability on known COB scenarios. A comprehensive program looks at all of these in order to ensure that you're capturing all the opportunity that goes beyond leads.

Chris: So it sounds like when we talk about COB and multiple coverage scenarios, there's a lot of nuance and a lot of detail that goes into these types of reviews. So when we're talking about this, it sounds like this is part of a full payment integrity solution, right? We're looking across the payment continuum and across claim types.

So we often see this materialize as including automated editing and policy application as well as review of correct coding and clinical accuracy or even as deep as waste and abuse reviews to target and find providers who may be mis-billing claims. But there's so much nuance, Evan, in kind of how you describe the COB world and what goes into some of those reviews and how the plans have to approach these claims and the billing accuracy from different angles for COB. So what would we expect to see—payers leveraging data assets and internal teams that we talked about—what are some of the other pieces of the puzzle that a plan should be looking for when it comes to COB accuracy specifically?

Evan: We do expect our plans to begin support of a COB program through those entitlement assets and maybe even a commercial other insurance asset as well too—that's expected, but let's also talk about some solutions that can exist in parallel with those as well.

So let's start with prepay. Ask yourself why your prepay editing doesn't include coordination of benefits either as a primary editor internally or as well as a secondary editor. Cotiviti's prepay COB solution can capture up to 25% of total program savings in prepay, ranging anywhere from Medicare and commercial other insurance and new discovery to incorrect calculations. This is unique to data assets as a claim-based intervention, as it helps prioritize membership at the right time. Seeking a vendor to perform expert validation irrespective of the intervention point is needed to maximize your plan value.

A prepay solution is also vital because speed is critical in coordination of benefits. Identifying COB scenarios creates cost avoidance, adding increased value to your plan and identifying these overpayments faster than a postpay solution. And in partnership to prepay, you need a robust postpay program to capture all the scenarios that we spoke about previously. COB, the concept, may be at times straightforward and up to little interpretation, but due to the constant changes your members experience and the investigatory nature of COB, a strong postpay program with thorough member-centric processes to assist with monitoring your membership, to intervene at the right time, helps make a program whole.

Chris: Working across the continuum is critical, so what we mean by that is both pre and postpay. So what are some of the things, Evan, that you feel that plans should be looking for from a vendor specifically who can perform in both areas, both pre and postpay?

Evan: Like we discussed, you're looking for experts and you're looking for a solution, so you don't need to manage so many different processes, points of contact, and capabilities across your COB solution. First, you're seeking COB experts with a strong understanding of MSP, NAIC guidelines, and state interpretation. Also interpretation of explanations of benefits (EOBs), plan language, and summary plan descriptions, and more. You're also seeking a team that can scale to your needs in supporting employer and provider outreach at the right time, identifying new and complex COB scenarios that go beyond the data assets we discussed. This vendor should be a full solution and provide the breadth and depth needed to maximize your plan value. Many plans and vendors may be confident in their approach for just half the picture as well, and typically that's Medicare other insurance, but you need experts across both Medicare and commercial other insurance.

Of Cotiviti's findings, roughly 50% of our savings is when a commercial other insurance is primary. You need to ask yourself if you're maximizing your value in this space. You also need a partner to assist in everything beyond coordination of benefits, including all things recovery. This is things such as dispute review, lettering, manual collections—everything collection and provider support. You also need a service, someone that can provide you documentation and interpretation for new concepts and opportunities, customer service, as well as reporting. All these tasks being supported by a vendor allows your internal team to focus on generating more savings and value and give you confidence that you're maximizing what you can in your program.

Chris: We see payers come to us with various setups from their internal perspective, so we see them with developing internal teams to teams that are completely built out with some background COB expertise in-house already. And we also see some who come to us with multiple outside vendors in the COB space. Do you see any additional value to having multiple vendors work that coordination of benefits in different past position configurations as well?

Evan: Absolutely. We see multiple different configuration points in COB. First, I would consider a vendor that can support you across the payment continuum, specifically seeking support and prepay. From there, there is value in a vendor stack to ensure you're capturing all opportunity needed in postpay as well too. At Cotiviti, we have experience in both first- and second-pass positions across various plans. For one plan, specifically, a large plan, despite being a second-pass vendor and that plan leveraging multiple different data assets, we still make up roughly 30% of the total overall COB savings—proof that expert review and a full service is vital to your program to ensure that you're maximizing the value.

Chris: Thanks Evan. That's a really great explanation of some of the complexity of COB and some of the reasons that plans might want to have multiple and different intervention points, including potentially different and multiple vendors stacked in postpay. There's obviously a need for supplemental data sources and quality data, and of course that human element that can apply these rules and how that expertise is so vital. So when we put that all together, it sounds like an ideal COB program might be somewhat unique to each plan, but in general, there are consistencies in what we see as necessary.

We fully expect plans to leverage an internal COB team; often this is the first line of defense. We see plans ingest data assets such as CAQH and membership and entitlement data to help supplement those reviews. And then we see plans use the capabilities and expertise of a full-service COB vendor to help span that gap between pre and postpay to ensure that these are working from both ends of the payment spectrum, including that validated identification of overpayments, that full-service quality vendor looks at everything, including provider support, employer outreach, recovery work, all the way through offsets and collection work as well.