By Ron Singh, senior vice president of coordination of benefits, HMS.
As healthcare policies, regulations and payment models continue to shift in response to the ongoing pandemic, payment accuracy has grown increasingly complex and important as health plans, providers and state agencies alike strive to uncover revenue and additional savings wherever possible. Ensuring the accuracy of billing and payment for Medicaid members has risen to the top of the priority list for payers, yet significant barriers to success remain.
Coordination of Benefits (COB), also known as Third Party Liability (TPL), is a cornerstone of payment accuracy and a high-powered cost control system that keeps provider’s and health plan’s healthcare programs strong. State Medicaid agencies and health plans, both public and private, use COB programs to ensure the appropriate payers are always billed for patient care. Around 20% of Medicaid members have access to other healthcare coverage, and it is often difficult for health plans and providers to identify when this is the case, contributing to astonishing waste, including the $56 billion of improper Medicaid spending in 2019 alone.
Allowing providers to operate with a full understanding of available benefits and enhancing efficiencies across the care continuum helps with getting the appropriate prior authorizations. There may be services covered in the commercial health plan but not under Medicaid, giving patients more options. Individuals can be dually enrolled in Medicaid, Medicare, and commercial health benefits, so when patients know the full scope of available coverage prior to care or billing, care teams operate more efficiently and increase patient satisfaction by maximizing use of all coverage sources.
COB programs have significantly helped to improve accurate payment and billing. However, amid the current health crisis and with Medicaid enrollment on the rise, organizations must strengthen payment accuracy efforts with real-time insight into eligibility and member coverage through the use of data-driven COB technologies. By utilizing these strategic solutions, healthcare organizations can improve care coordination and billing, reduce unnecessary costs and ensure providers are reimbursed correctly the first time.
Best Practices for Enhanced COB Programs and Efforts
With the adoption of COB and payment accuracy solutions, Medicaid agencies and health plans can quickly identify all relevant coverage at the point of enrollment or prior authorization, helping to preserve the integrity of Medicaid as a payer of last resort and significantly reducing costs and administrative burdens for both payers and providers.
The rapid collection of member data in various formats from multiple sources, for example, is a major component of COB success. The data needs to be constantly refreshed and should cover all claim types so that it meets members’ needs based on their fast and frequently changing healthcare coverage. To ensure the best possible match, organizations also need detailed data from all major health plans, as well as state and regional plans made accessible via payment accuracy technology.