increasing cost avoidance for medicaid cob€¦ · invoice submitted to incorrect health plan....

© 2018 CAQH, All Rights Reserved.

Increasing Cost Avoidance for Medicaid COB

Anthem Government Business Division (GBD)


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Logistics: How to Participate in Today’s Session

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Webinar Speakers

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Laura CarrawayDirector of OperationsAnthem Government Business Division (GBD)[email protected]

Kelly McNair Manager, Business [email protected]

mailto:[email protected]



Addressing the Industry’s ChallengesIntroducing Anthem GBDChallenges with Previous COB ProcessWhy Anthem Chose COB SmartAnthem’s New Process for Finding COB Information Lessons Learned and Next StepsQ & A

Agenda

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© 2018 CAQH, All Rights Reserved.Confidential & Proprietary.

About CAQH and the Members

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CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients and health plans.

CAQH BOARD MEMBERS

http://www.aetna.com/

http://www.antheminc.com/index.htm

http://www.ahip.org/

http://www.aultcare.com/

http://www.bluecares.com/

http://www.bcbsm.com/

http://www.bcbsnc.com/

http://www.bcbst.com/

http://www.carefirst.com/

http://www.cigna.com/

http://www.horizon-bcbsnj.com/

https://www.kaiserpermanente.org/

http://www.unitedhealthgroup.com/


Industry COB Challenge: “Reactive” Strategy Occurs After Claim Submission

Missing or inaccurate patient information.

Results:Manual data gather and validation processes.

Lack of uniform use of billing codes, complicating COB reviews.

Results: Extra paperwork from denials and resubmission.

Invoice submitted to incorrect health plan.

Results: Repeat bills.

Ad-hoc patient data requests.

Confusion over primary health plan COB payment.

Results: Significant manual turn-around time.

Confusion over health plan payment (i.e., ambiguous EOB).

Results: Lengthy and manual secondary COB bill submissions.

Claims payment disputes from members.

Results: Manual work associated with non-standardized appeal processes.

Patient Access and Eligibility

Provider Billing / Claim Receipt Routing

Claim Adjudication

EOB/Claim Payment

Appeals & Adjustments


Letters are confusing and frustrating

Claims are not paid correctly or on time

Result: Negative Impact to Plans, Providers, and Patients

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Extensive phone calls to offices

Claims are not paid correctly or on time

High monetary costs of letters and processing

Low survey response rates

Overpayments or incorrect payments

Extensive use of expensive vendors

High administrative burden

$800 million Estimated costs of COB

administrative inefficiencies

Impact to Plans Impact to Providers Impact to Patients


A Unique Challenge—and Opportunity—for Medicaid Plans

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State requirements to intake and utilize state generated data create quality and consistency challenges across multiple platforms.

Medicaid beneficiaries often have multiple breaks in coverage in a single year, causing data to quickly become outdated.

13% of Medicaid beneficiaries report having other coverage.

As the payer of last resort, Medicaid plans have the greatest opportunity to save money through accurate COB.

UNIQUE CHALLENGES UNIQUE OPPORTUNITY


Take a Proactive Approach to COB

Identifies individuals with overlapping coverage across

multiple health plans.

Shares complete COB information with

health plans and appropriate providers.

Built-in primacy engine

determines the order of benefits.


Achieve Better Results at a Lower Cost

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Minimize overpayments/

incorrect payments

Decrease COB costs per member

Use vendors more

effectively

Make better use of staff

time

Deliver an improved member

experience


COB Smart Takes a Completely Different Approach to COB

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Free from conflict of interest

Focuses on prevention

No Incentive for inefficiency

Delivers highly accurate, updated data

Identifies data for the exclusive benefit of the health plan, not to charge recovery fees.

Gives data to health plans on a prospective basis.

Charges a predictable, per member per year fee for all services.

Only national coverage database that is supplied and maintained directly from health plan supplied data on a weekly basis.


35 Plans from Across the Country are Participating in COB Smart

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*

* Going Live in 2019


Anthem

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VISIONTo be the most innovative,

valuable and inclusive partner.

nearly 40+ milliontotal medical members in affiliated health plans

1 in 8 Americans

over 6,374 millionMedicaid members


Challenges of Prior Process

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PRIOR PROCESS:

Relied on numerous vendors and state files

for validated data.

Challenges with previous data sources:

Incomplete

Expensive

Outdated (updated twice a month or monthly)

Low quality


Selection Criteria for COB Smart

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Weekly updates track members rapidly coming on and off coverage.

Cost savings per member per year compared to vendor costs.

High quality data to deliver a better member experience by paying claims correctly.

Robust participation from other plans to ensure adequate data coverage.


New Process Using COB Smart

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COB Smart data received by dedicated COB Smart business analysts.

Automatically upload into the system.

Vendors and team conduct manual review of all data.

Contact plans through COB Smart portal to verify information by dedicated COB verification specialists through workflow tool.

Receive Data Triage QA Upload

Workflow tool routes data from other sources to regional staff focused on intakes and processing.

Data eligible for automatic upload (25% of the file).

Needs additional review (75%).

Needs additional review. 100% of the data.

No QA needed.

Manual upload after verification.

Manual upload after verification.


Benefits of Using COB Smart

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3-5% Increase in cost avoidance for automated COB Smart

data applied.

$Cost savings from using CAQH over more expensive

vendors.

Continuous improvement through sharing best practices with COB

Smart network of plans.

REPORTING:

Monthly report tracks source of all data broken down by market.

Determines value from state files, COB Smart files, and manual files.


Lessons Learned:

Lessons Learned and Next Steps

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Automation is beneficial, but don’t fully automate immediately. Create business rules that allow for both automation and manual loading.

Treat COB Smart as a separate program, not just another data source.

Put processes in place to determine how best to leverage the data based on the quality by carrier and the touchpoints in your market.

Successful implementation requires an IT investment. Be ready to intake the data as well as extract quality data back to CAQH.

Better utilization of analytics and develop synergy with the IT team for better monitoring.

Expanding scopeof the

Medicare business.

Developing moredetailed reporting to track

source for recoveries

Goals Moving Forward:


Audience Questions and Answers

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Please submit your questions

Via the Web:Enter your question into the

“Questions” pane in thelower right hand corner

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Contact Us

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Kelly McNairManager, Business [email protected]

[email protected]

@CAQH



increasing cost avoidance for medicaid cob€¦ · invoice submitted to incorrect health plan....

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