Coordination of advantages (COB) is a key part of any efficient fee integrity program. However figuring out primacy for members with a number of plans and guaranteeing claims aren’t overpaid is usually a sophisticated course of. Whether or not it’s verifying employment standing or sifting by means of sophisticated claims, COB takes important time for peak accuracy. And whereas well being plans deal with the intricacies of an efficient COB technique, many overlook the probabilities {that a} complete prepay COB answer can provide as a worthwhile part.
Prepay or potential COB takes efficient COB a step additional, eliminating the necessity to right errors after the very fact by pausing the declare course of to verify correct info and correct order of advantages earlier than fee. When carried out appropriately, prepay COB has the potential to not solely stop overpayments but additionally to make sure correct member profiles, increase price avoidance, and decide main fee duty sooner. All this stuff mix to decrease supplier and member abrasion and enhance worth.
Whereas most, if not all, payers agree that there’s important worth in prepay COB as a part of an general COB technique, and to fee integrity efforts on the whole, taking prepay COB from an idea to actuality stays considerably mysterious for many plans. This can be attributable to a scarcity of readability across the distinction between an asset and an answer, in addition to frequent misconceptions surrounding how a full-scale prepay COB answer works and the worth it might ship.
The worth of prepay COB
Prepay COB gives three main advantages: Administrative price financial savings, pace, and long-term worth.
Administrative price financial savings
Maybe the obvious good thing about potential COB is administrative financial savings. Quite than deploying expertise and incurring important prices to recuperate funds from a supplier that was paid in error, prepay COB avoids the inaccurate fee within the first place, decreasing the hassle required to allow funds based mostly on an correct order of profit willpower. By pausing the declare course of, plans save important prices that will in any other case be spent chasing down overpayments. Eradicating the necessity to recuperate medical spend, prepay COB reduces the burden on plan assets and suppliers and helps plans to streamline administrative efforts up entrance, whereas creating capability to redeploy expertise to different worthwhile work.
Velocity
Because of this, eradicated must chase down fee, and pace turns into a major good thing about prepay COB as properly. To fulfill prompt-pay laws, pace is a vital profit for avoiding penalties or with the ability to recoup funds in any respect. For instance, in Texas, plans are solely permitted to recoup funds from suppliers inside a six-month window. If that point expires, the chance to realize fee accuracy is over. Prepay COB may also help to seize most worth earlier than time runs out.
Lengthy-term worth
Administrative prices and pace to worth are vital on their very own, however potential COB additionally creates a system that inherently gives perpetual worth. Over time, prepay COB helps save prices by operating on groomed and correct knowledge, which is each up-to-date and infused with experience tailor-made to a selected well being plan. It isn’t nearly executing on a set of linear steps—prepay COB carried out appropriately is a complicated course of that requires understanding when, how, and the place to make use of knowledge.
For instance, one nationwide plan that adopted prepay COB was in a position to save an estimated $48 million in 2025 alone and create a large suggestions loop by making use of insights to tell future methods. This plan was additionally in a position to notice financial savings on greater than 99% of all claims recognized for prepayment.
Prepay COB in motion
Prepay COB might be utilized in a wide range of completely different situations. Just a few particular prime candidates embrace:
- Medicare different medical insurance (OHI) for incapacity: Figuring out Medicare for members entitled based mostly on incapacity is particularly worthwhile as a result of these circumstances usually lack main indicators equivalent to age and outlined medical circumstances. With out these triggers, disability-based Medicare protection can stay hidden, resulting in incorrect main legal responsibility for the well being plan. By confirming this protection and figuring out the order of advantages earlier than a declare pays, plans can guarantee correct COB, stop pointless funds, and shift prices appropriately—delivering financial savings whereas defending profit integrity.
- Newborns: Automated new child protection covers a new child for a set interval below a father or mother’s current plan. This ensures speedy protection at start, even earlier than the kid is formally added to a coverage. Contemplate a state of affairs the place there are new child multiples. Leveraging a prepay COB answer could allow a plan to pause a declare for one new child, right the order of advantages, and apply that discovering to the remaining siblings, assuming the identical twin protection applies. In situations equivalent to these, prepay COB processes can guarantee well timed fee to suppliers with out sacrificing accuracy.
Going past knowledge belongings
Advanced knowledge goes hand in hand with advanced claims. Nonetheless, there’s a typical misinterpretation that prepay COB is solely the power to execute common COB processes utilizing knowledge sources. In principle, accessing knowledge belongings ought to present sufficient info to have the ability to pause claims and conduct a COB evaluation, however in observe, this usually proves to be tough to scale. Plans can’t pause each single declare that comes by means of and may simply be overwhelmed by the necessity for administrative assets, experience, and knowledge cleaning to make prepay COB work successfully.
Having good knowledge is only one piece of the prepay COB puzzle. An entire evaluation requires specialists to not solely confirm knowledge but additionally have the experience to know the place there are gaps and tips on how to interpret the information as soon as secured.
An efficient prepay COB technique builds, anticipates, and navigates a course of that’s usually nonlinear. With the ability to seize financial savings prepayment isn’t nearly determining if there may be one other coverage that covers the member, however may additionally require a detailed examination of variables equivalent to:
- Working standing of the member
- Employer group measurement
- Profit exhaustion
- OHI-related nuance
Executing potential COB properly means being acquainted with all of a declare’s parts and understanding what to search for, not simply leaning on knowledge belongings.
Establishing for fulfillment
Going above and past to execute prepay COB hinges on having sturdy parts and a robust crew. Contemplate whether or not your plan can: carry out knowledge enrichment, prioritize claims eligible for prepay COB, and incorporate a real pause-and-review potential performance.
Carry out knowledge enrichment
Only one dataset is just not sufficient for figuring out fee duty and figuring out primacy, and manually managing this knowledge is unscalable for a lot of. Contemplate investing in an answer that may detect areas the place knowledge is lacking, incorrect, duplicated, or outdated, and leverage the experience of COB knowledge professionals to rectify and improve the dataset. Knowledge could must be supplemented with a spread of public and proprietary sources to shut gaps.
Prioritize claims eligible for prepay COB
It isn’t possible to evaluation each declare prospectively for COB, nor to comb by means of huge entitlement datasets. An efficient prepay COB answer ought to analyze knowledge to find out precedence, incorporating machine studying to establish doable situations of main different medical insurance protection.
Maintain it human
As a lot as synthetic intelligence and automation can gasoline pace to processes, a posh space like prepay COB requires human experience and decision-making. Auditors can uncover essential particulars to precisely set up the order of advantages that will not be doable with know-how alone. Remaining up-to-date and compliant with varied COB necessities, together with these codified within the Medicare Secondary Payer Act (MSP) and the Nationwide Affiliation of Insurance coverage Commissioners (NAIC) tips, in addition to state legal guidelines, makes expertise much more worthwhile.
Prepay COB is a worthwhile part of an general fee integrity program and any COB technique. By pausing claims and figuring out the correct order of advantages earlier than fee, plans can discover a litany of advantages. They save on administrative prices, pace alongside the method, and achieve incremental worth over time by refining knowledge and limiting supplier and member abrasion. Whereas it takes greater than a strong knowledge useful resource, investing in the correct accomplice, answer, and specialists can present important return on funding.
About Naomi Murphy, J.D.
Naomi Murphy oversees operations and product technique for Cotiviti’s COB Validation and Knowledge Mining options, delivering streamlined worth era for shoppers. A flexible operations chief, Naomi has a demonstrated observe file of delivering operational excellence, leveraging predictive analytics, and accelerating progress.
