The Concept

The concept behind coordination of benefits (COB) is fairly straightforward and simple.

In situations where a patient has multiple health plans, it’s a way for commercial and government insurers to determine which payer is responsible for coverage, in what amount, and in what order — as a primary, secondary or tertiary payer. 

For instance, two spouses may pay for health insurance under each of their employer’s plans, so each would be covered under their plan and their spouse’s plan. Or a single person may have Medicare and additional health care coverage under a supplemental plan. Coordination of benefits helps determine the fair share owed by each health plan when a claim is submitted and, in doing so, it also helps prevent duplication of benefits.

Once a patient’s primary health plan is determined, the benefits that he or she is eligible for under the primary plan must be provided regardless of whether there is a secondary plan. Once the primary plan has paid its share of the reimbursement as stipulated by the coordination of benefits, then the secondary plan kicks in. 

The secondary health insurance plan assesses what health insurance benefits have been provided by the primary health insurance plan, then determines if there is any remaining balance due. However, the secondary payer is not required to cover the outstanding balance, especially if the primary payer deemed that the provider invoice amount was not “usual, customary, and reasonable.”  When this happens, the patient may still be on the hook financially for the remaining monies. 

The Execution 

In practice, however, COB can be anything but simple. In fact, it’s often ponderous and confusing. 

When coordination of benefits comes into play, health plan members often find themselves fielding a barrage of explanation of benefits (EOB) documents from multiple payers, all of which may be difficult to decipher and piece together.

Meanwhile, providers often have to take patients at their word about primary and secondary insurance plans, only to receive contradictory information when the EOBs arrive. Providers are also left to try to manually keep track of everything, monitoring payer portals, emails, faxes and phone calls. 

COB at the Point of Care 

Like a lot of things, coordination of benefits could be greatly improved by introducing more transparency into the process and doing so much earlier in the patient/member journey.  

That’s where Myndshft hopes to help.

When a provider performs an eligibility and benefits verification check with Myndshft, we can now identify other payers — even when they are not included as part of the eligibility request — and return detailed information on primary, secondary and tertiary payers as part of a consolidated response. All within less than a second. All with just a single API call. All within a provider’s existing systems and workflows. 

It works like this:

When an eligibility check is performed, Myndshft will check for any other payers that are applicable to the services being rendered to the patient.	If another payer is identified on the primary eligibility request performed, Myndshft will attempt another eligibility check for that payer.	If another payer is determined to be the “true” primary payer, Myndshft will reorder the payers to return the correct ordinality; this also applies to the secondary payer.

We can even identify errors included as part of an eligibility and benefits verification request and automatically correct it so that it generates an accurate response about a patient’s benefits for a specific service, for the network status that is appropriate, and for all their payers in scope.

This automated process saves administrative personnel from the tedious task of accessing multiple payer portals and sifting through documentation to identify the primary payer. 

By receiving COB information as part of the eligibility and benefits verification process, healthcare providers can now have a much better sense for what services they’ll need to bill to each payer, as well as for the amount the patient will be financially responsible. 

Understanding how much to bill each payer, and having any errors corrected before requests are submitted to payers, will also contribute to cleaner claims and fewer denials. 

Patients and payers stand to gain too. 

During the intake process before they’ve even received medical care, patients covered under multiple health insurance plans can be informed of the amount that they will be financially responsible for and what will be covered by their health plans. No surprise envelopes in the mail a few months after the fact. 

And because providers who use Myndshft’s coordination of benefits solution are able to send clean claims to the right payer on the first submission, payers are saved from unnecessary administrative work on their end. Plus, health plans also know if a patient has another payer and are able to coordinate data exchange more effectively with the new CMS rules.

Conclusion 

Coordination of benefits performs an essential function in what can be a complex healthcare claims reimbursement process. 

Where COB often falters, however, is that it is typically shrouded and opaque, and usually only reveals itself when recipients receive explanation of benefits statements, in many cases months after treatment has been provided. That’s too late in the process and can set off a cascade of claims rework and unnecessary correspondence between providers, payers and patients. 

Revealing COB details at the point of care brings it to light when it is needed most; before treatment has been received, and before a claim has been submitted. 

To see Myndshft’s Coordination of Benefits solution in action, please contact us to schedule a demo.