Industry experts estimate that about 7-10% of claims submitted to health plans require coordination of benefits, a significant portion of which result in secondary payers reimbursing providers for care that should have been covered by a primary payer. Ultimately, COB with other carriers based on eligibility can cost as much as 2-4% of total claims costs.
SCIOinspire assists healthcare payers with a customizable rules engine for identifying potential COB cases that can be configured to reflect payer-specific and state COB guidelines. It also supplies a configurable link to the health plans eligibility database for updating member COB information, as well as a module to manage member outreach.
Pain Points
Healthcare payers are challenged by:
- COB costs can exceed 2-4% of total claim costs
- Difficulty in isolating COB claims through manual processes
- Resource-consuming management of member outreach, communication
- Complexity of determining order of benefits and payers
- Management of recovery efforts and ultimate reconciliation
- Lack of efficient workflow processes and supportive technology
- Weak reporting methodologies
Value Proposition
- Dynamic leadership - Management team with decades of experience in developing, implementing and managing national-scale COB programs
- Superior financial results - Sophisticated, client-customized programs maximize ROI
- Best-in-class outreach services - Multilingual call center including English and Spanish supported by cutting-edge technology
- MY COB™ software a rule-based application that automates COB processes and creates a defensible audit trail
With SCIOinspire, clients are able to customize their COB efforts via select modules:
COB-Identify
- Outreach activities using various methods to identify and confirm COB, including effective dates
- Clients notified of members with confirmed COB, to ensure prevention of primary payments going forward - results in significant avoidance savings
- Program pricing based on a per member fee
COB-Audit
A review of paid claims for members with other primary coverage can lead to identification of significant overpayments resulting from incorrect COB application errors, including:
- Failure to identify existence of COB
- Manual, error-prone, COB calculation process
- Complex claims processing rules
- Interpreting multiple EOB formats
The SCIOinspire process consists of :
- Receipt of paid-claims feed
- Gaining access to COB policies
- Applying system claim filters
- Conducting manual claims review
- Identifying over-payments
- Initiating refund process
COB-Post Pay
SCIOinspire COB-Post Pay model encompasses a comprehensive range of services:
- Data Import SCIOinspire receives data feed from clients via a secure transmission protocol
- Identification SCIOinspire targets a prioritized list of members for COB outreach (versus a blanket approach). Selection factors include:
- Type of COB program (recovery or PM based)
- Member medical spend
- Member demographic information
- Date of last COB inquiry
- Existence of spouse/dependants
- Benefit usage
- Diagnosis
- Any client specifications (blocking list, additional client rules)
- Investigation COB information collected and confirmed (primary carrier, effective dates, etc.). In addition, COB outcomes are transmitted to clients, ensuring appropriate COB indications on future claims. SCIOinspire then launches determination (OOBD) processing:
- Responses received via multiple sources (mail/phone/fax)
- System validation applies NAIC and MSP rules
- Rules-based engine
- Customizable set of rules determines which insurance should pay first
- Rules-based logic for each case 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 purchased)
- Refund Request SCIOinspire conducts paid-claim sweeps based on COB effective dates, allowing overpayments to be identified and finalized. At that point, customized provider refund letters are generated that include overpayment detail and primary carrier indication. The SCIOinspire call center staff is well trained to handle any questions or disputes. Finally, overpayment recovery results are reported to the client according to an agreed-upon schedule.
- Recovery/Reconciliation SCIOinspire receives and processes refund checks, which are endorsed to SCIOinspire, and refunds are deposited into the SCIOinspire escrow account. Net pay remittance minus fees, along with supporting reports, are submitted to the client monthly, while offset/downpaid refunds are detailed in an invoice sent with total fees due to SCIOinspire.
COB-Eligibility
SCIOinspire provides an advanced technology solution designed to extract member eligibility updates by accessing client systems to update correct eligibility. At the same time, the system reconciles eligibility discrepancies identified during the process. SCIOinspire's global delivery model and staff expertise enables clients to achieve significant administrative efficiencies.
SCIOinspire delivers a complete suite of full-service COB software available as a software-as-a-service application or as a licensed application for internal hosting. MY COB allows health plans to identify COB claims, streamline and manage the recovery of incorrect payments, and build comprehensive databases to prevent future incorrect provider reimbursements.
Additional Product and Services Information
- Coordination of Benefits Recovery Services
