Lower costs by automating coordination of benefits

Determining payer order is key to lowering costs

Why is payer order so difficult to decipher? Firstly, health plan memberships fluctuate constantly. Members move in and out of plans due to life-changing events such as marriage, new jobs, retirement, or becoming disabled. Amid change, even members aren’t always sure which plan is their primary payer.
 

Shift from misaligned to straightforward

While providers and payers move through the stages of figuring out the correct payer order, members sometimes find themselves stuck in the middle. If the dispute drags on long enough, members can be denied services by the providers until it’s resolved.

The best way to control costs and smooth tensions between providers, payers, and members is to ensure the correct plan is paying the right amount at the right time — that’s where we come in. Using data mining, we’re able to recognize patterns and identify overlapping coverage. We help your health plan find leads by comparing your membership list against third party membership lists to detect other healthcare coverage members might have.
 

Turn leads into action

Once leads are generated, the right rules and policies must be applied as part of the COB process. Every healthcare plan, each state, and the federal government has rules and policies that must be followed.

Rather than apply those rules manually — which is tedious and expensive — we automate the process. This reduces errors and accelerates processing. We use queries that go beyond traditional COB approaches to detect more overlaps and boost value.

After the right payer order has been determined we can update your files to reflect the correct payer order, so any future claims associated with this member and their family are paid correctly.
 

Forward-thinking automation

Historically, COB has been time-consuming and highly manual. We’re here to change that. In addition to automating the application of rules and policies, we automate as many of the manual steps as possible — which increases accuracy and reduces the need for members and providers to contact your call center with questions. Costs are controlled and neither group feels stuck in the middle.
 

Workflows that work for you

Navigating numerous incompatible systems — or worse — searching for data that hasn’t been digitized, inflates administrative costs. Our solution automates this, too. We deliver a list of incorrectly paid claims to you through our collaborative online workflow tool. Claims are prioritized by value and other considerations — such as their recovery expiration date.

The workflow tool also includes a reporting suite that reveals key insights and information about overpayments. For claims that are too complex to be automated, our subject matter experts share critical information with you using the workflow tool. Having all the facts will help you make a better informed decision about payment order. Once your membership list is updated with the correct primacy determinations, claims will be paid correctly going forward.
 

Payer order is clearer with Carelon

You deserve a COB solution that accelerates the process and improves costs. Contact us to learn more about the possibilities and impact of our Coordination of Benefits Solution.