With a significant increase in dual-income families and the average age of Americans rising, the likelihood of individuals having multiple benefits plans has also grown making the identification and coordination of health benefits (COB) more challenging. An effective COB program can achieve a 5% savings through avoidance and 0.5% in recoveries roughly $5 million for a 500K life plan.
MY COB™ enables health plans to manage the entire COB identification, prevention and recovery process end-to-end in order to:
- Identify and focus on accurate and timely payment of COB claims
- Streamline and manage the recovery of incorrect payments
- Build comprehensive databases to prevent future incorrect provider reimbursements
In fact, health plans can recapture up to 20-30% more paid COB claims revenue than with conventional COB approaches, while improving productivity and compliance during the process.
Healthcare payers are struggling with:
- Increasing number of COB claims
- Financial drain correlating to this increased volume
- Difficulty in identifying COB claims due to disconnects between eligibility and claims applications
- Complexity of managing member outreach, communication and response
- Inefficient manual and paper-based processes
- Automates all components of COB processing
- Imports, filters, and scrubs claims
- Targets prioritized list of potential COB claims
- Manages member communications
- Determines the primary payer, order of benefits for each member, sequence for payment and precise refund due
- Updates member information frequently to prevent future COB payments
Powered by the latest Microsoft .NET-based technology, MY COB features an advanced rules engine that derives logic from regulatory state specific NAIC, CMS standard and Medicaid guidelines. With this robust technology at their fingertips delivered via SaaS or licensed for internal hosting health plans can update member information more frequently, prevent unqualified reimbursements better, plug vital information gaps consistently, and recover more effectively all while reducing errors, increasing productivity, and improving regulatory compliance through audit trails and reports.
MY COB relies upon an advanced data importer to collect claims information. The application identifies potential COB cases by processing claims data through a robust, customizable rules engine. Eschewing a typical blanket approach, SCIOinspire targets a prioritized list of members with selection factors including:
- Type of COB program (recovery or PM based)
- Member medical spend
- Member demographic information
- Date of last COB inquiry
- Existence of spouse/dependents
- Benefit usage
- Diagnosis
- Any client specifications (blocking list, additional client rules)
Member outreach is then initiated using a variety of methods such as outbound calls and paper questionnaires. When member responses are received, MY COB applies NAIC and MSP rules for validation. Subsequently, the application:
- Utilizes a customizable set of rules to determine which insurance should pay first
- Employs logical case analysis to determine the order of benefits for each member
- Determines sequence order for payment (secondary, tertiary, etc.)
- Identifies and calculates any overpayment (triggering recovery activity, if appropriate)
- Data importer to collect claims payment information
- Robust, customizable rules engine to identify potential COB cases configurable to reflect payer-specific and state COB guidelines
- Module to manage member outreach
- Configurable link to the health plan eligibility database for updating member COB information
- Case management module with advanced workflow for managing the cases from creation to resolution and recovery featuring components for compliance and audit purposes
- MY COB Coordination of Benefits Identification and Case Management Software Application
