A Clearer Path to Coordination of Benefits

COB Considerations for Medicaid MCOs

Coordination of Benefits. Many Medicaid health plans will tell you that this area is a primary concern in their payment integrity program. It’s no wonder: statistics tell us that 4-8% of Medicaid MCO membership has other healthcare coverage, but that number is much higher than what most COB solutions on the market are able to identify. What’s left is a costly gap. If you are wondering how your health plan can optimize coordination of benefits activities, read on.

A Look at What’s Involved with Coordination of Benefits (COB)

The Centers for Medicare and Medicaid Services (CMS) outline a specific process for COB which is summarized below:

1. Correctly paying claims after first identifying other applicable health benefits
2. Coordinating payment process in which the primary payer is billed first
3. Making Medicare eligibility data available to other payers (includes transmitting Medicare-paid claims to supplemental insurers)
4. Managing claim payment process so that no improper payments are made (payment integrity)
5. Part D benefit coordination

Note that much of this process requires coordination, transmission, and visibility into the claims process in order to be compliant. Additionally, and according to CMS’s website, “COB relies on many databases maintained by multiple stakeholders including federal and state programs, plans that offer health insurance and/or prescription coverage, pharmacy networks, and a variety of assistance programs available for special situations or conditions.”

With so many databases and areas of coordination and regulation, it’s easy to see how this seemingly clear process can become a Medicaid MCO’s nightmare. That’s where integrative technology can be especially helpful for Medicaid health plans, but only if the solution eliminates inefficiencies and provides better access to needed data.

COB Pain Points for Medicaid MCOs

The COB process outlined by CMS is intensive; an MCO has to coordinate benefits with other providers, establish third party liability, share eligibility data, and manage payment integrity. Without the right COB solution, this process is manual, fault-prone and inefficient. However, a total payment integrity program like Pareo™ offers a comprehensive solution for Medicaid MCOs.

Here are some specific pain points in benefits coordination that Pareo addresses:

Dual Eligibles

Dual Eligibles, or those beneficiaries enrolled in Medicare and also qualified for Medicaid coverage, make up about 21% of beneficiaries nationwide. Pareo has built-in tools that identify overlap for dual eligibles and beneficiaries that are enrolled in private health plans. In part, this is done by culling available data from a nationwide database meant to identify individuals with overlapping coverage.

Third Party Liability (TPL)

Generally speaking, Medicaid is identified as the payer of last resort for billing. Third-party liability can require dedication of some serious resources for Medicaid MCOs, because it is often up to a health plan to manage this process. This includes (in very general terms) identifying third parties that may be liable, the amount of liability, and payment recoveries. In January of 2015, the United States Government Accountability Office (GAO) published data that estimated 13.4% of Medicaid enrollees also had private insurance. The report projects this number to change along with Medicaid coverage.

In line with TPL compliance, CMS requires mandatory reporting under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). The purpose of Section 111 is to “enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries.” Unlike some COB solutions, Pareo can streamline this reporting process for clients, ensuring compliance measures are met and data is properly reported.

Payment Oversight

COB payment oversight means that MCOs are subject to specific regulations regarding payment recoveries. These areas may include “MCO ‘pay and chase’ activities, out-of-network coverage, and discovery and recovery responsibilities.” Medicaid health plans  have to pay careful attention to payment recoveries in order to avoid improper payments.

As a COB solution, Pareo identifies overpayments retrospectively and prevents future overpayments automatically. Because a Medicaid MCO must ensure no improper payments are made, a solution like Pareo is helpful because it gives visibility and transparency to payment oversight. Managing compliance is much easier when a fail-safe internal process is in place.

New Solutions for Benefit Coordination

Technology has created a more affordable, more comprehensive solution for Medicaid MCOs. Total Payment Integrity™ helps Medicaid MCOs manage Coordination of Benefits through a single integrative, intuitive, and comprehensive platform. When COB is looked at in conjunction with other elements of a healthy payment integrity solution, a Medicaid MCO saves time and money.