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Case Study
Full-Spectrum Coordination of Benefits Solutions Help Regional Plan Boost Savings
Summary
Discover how a regional carrier generated 250%+ ROI and increased yearly collections by $500,000 with comprehensive coordination of benefits (COB) solutions.
Customer
Regional commercial health insurance carrier with approximately 500,000 covered lives and $2.5 billion in annual claim spend.
Challenge
The health plan sought to identify primary coverage sources for its commercially covered population.
Products
Coordination of Benefits Services, including prospective cost avoidance and retrospective recovery.
Results
- >250% ROI.
- >$500K increased yearly collections.
- Increased the plan’s total savings by $4.66 per member per year (PMPY): $1.26 PMPY cost avoidance and $3.40 PMPY retrospective recovery.
- Results achieved in the second-pass position.
The Customer:
The commercial health plan has about 500,000 members and is rated excellent by the National Committee for Quality Assurance (NCQA).
The Challenge: Creating Clean Claims
The plan had several existing coordination of benefits (COB) vendors but believed second-pass scrutiny by Change Healthcare could uncover additional savings.
Areas targeted included prospective cost avoidance, or the identification of alternative primary coverage before a claim is filed, and retrospective recovery, or the illumination of claims previously paid in error due to undetected alternative primary coverage.
Reducing inaccurate claims and payments has become essential for most health plans as they grapple with the extensive, ongoing member churn accentuated by the pandemic.
Under the best of circumstances, ensuring accurate COB is a major challenge. An array of frequently changing variables, including benefit changes and plan modifications, make verification of primary coverage a moving target and, hence, chronically susceptible to error.
The Solution: End-to-End Prospective and Retrospective Solutions
Despite COB programs already in place, the health plan was confident Change Healthcare’s solution could improve their COB cost avoidance.
Chief among the benefits of the Change Healthcare COB solution is the leading technology used to identify alternate primary coverage and potential for erroneous payments, as well as the unprecedented scope of our data lake, which provides access to the records required to quickly and correctly execute coverage assessments and determinations.
The data lake, unlike other vendors’ data sources, frequently refreshed records to include not only medical claims but also dental, vision, pharmacy, behavioral health, and more. This diversity improves matching opportunities to speed coverage identification and confirmation.
Change Healthcare additionally relies on a range of intelligent automation and artificial intelligence tools, including proprietary, machine-learning algorithms, to deliver best-in-class matching capabilities. These tools incorporate National Association of Insurance Commissioners (NAIC) screening rules governing the identification of primary and secondary coverages.
Finally, as an operator of one of the nation’s largest electronic claims clearinghouses, Change Healthcare has the capacity to ping carriers in real time to further verify an individual’s coverage status.
Taken together, the end-to-end COB approach consistently produces an accuracy rate of 99%.
The Result: Rapid Cost Reduction
Change Healthcare deployed both prospective cost avoidance and retrospective recovery capabilities on behalf of the plan. Implementation planning was conducted in close coordination with the health plan and included a number of customizations to ensure data compatibility.
Through the first six months of operation, Change Healthcare COB solutions increased the plan’s total savings by $4.66 per member per month (PMPY). That included $1.26 PMPY in prospective cost avoidance and $3.40 PMPY in retrospective recovery.
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