Electronic Health Reporter

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.

Alongside timely access and insight into copious amounts of data, the most sophisticated COB programs need to utilize smart technology to reduce the administrative burden that contributes to payers and providers billing incorrectly. Artificial intelligence functionality can help to score data, enabling payers to target erroneous claims that are most likely to be recovered. Furthermore, advanced matching logic incorporates thousands of algorithms focused on common names, family connections, cross state matches and more to identify most third-party liability matches. Payers and other healthcare organizations are upgrading their COB solutions to those that leverage machine learning capabilities to more easily connect coverage information to the correct individual and boost accurate billing practices by eliminating the opportunities for administrative error.

Not only do solutions need to be smart but they must also be fast and flexible to ensure payers can make timely, accurate payment decisions for optimal results. To be effective, organizations should look for coverage at the time of enrollment, prior authorization, point of billing, adjudication, and post-payment. It’s particularly important to discover primary coverage at enrollment—by doing this, providers gain efficiency and have the opportunity to improve revenue and cash flow from billing the right payer from the start.

Facilitating Better Care Coordination for Payers, Providers & Patients

The coordination of patient benefits is critically important to the success of the American healthcare system, especially as safety-net programs like Medicaid are experiencing enrollment surges due to the COVID-19 pandemic. The added pressure of these care demands has made it more important than ever to get payments right. By equipping payers and providers with COB and Medicaid member information when they need it, healthcare organizations are better positioned to pay the right claim in the right amount, reducing overpayments, denied claims and time spent executing pay and chase efforts. This is imperative as organizations must focus reduced staff resources on serving members with critical enrollment, accessibility and benefits processes — not pay and chase.

Without the intelligent integration of patient health data across various sources, understanding a patient’s full range of health benefits can be more than a heavy administrative burden — it can be impossible – creating a barrier to healthcare for vulnerable populations and driving up wasteful spending within the healthcare system. Services covered by commercial health plans versus Medicaid versus Medicare vary widely. When coordinated properly, the patient will typically have lower out of pocket costs when using their full coverage available to them.

When payers and providers work together to continuously verify this information throughout the care continuum, it helps to expedite the reimbursement process, while improving the bottom line for both payers and providers. With the help of innovative, data-driven technology, healthcare organizations are proactively identifying all coverage sources prior to the point of care and improving payment accuracy levels across the board at a time when savings and proper reimbursement are needed most.