Accurate Coordination of Benefits Helps Health Plan Achieve $73 Million in Upfront Cost Avoidance

“We knew we were not getting the cost savings we should be seeing from other solutions.”

-Director of Payment Integrity at large health plan

Customer

  • Large Health Plan

 

Challenge

  • The health plan sought to identify primary coverage sources for its Medicaid population

Products

 

Results

  • Realized cost avoidance savings of $2.2 million in first month of initial pilot program
  • Achieved cost avoidance savings of $25.9 million within eight months of initial pilot program
  • Implemented medical Coordination of Benefits program in 20 states and pharmacy Coordination of Benefits program in 15 states
  • 2019 cost-avoidance savings of $73 million

The Customer

Change Healthcare partnered with a large national health plan to identify primary insurance coverage for its Medicaid population. Although the plan relied on several existing Coordination of Benefits programs, its leadership knew that significant primary coverage remained unidentified.

The Challenge: Determine Third-Party Liability

To remain the payer of last resort, Medicaid payers must first determine the existence of any alternate coverage sources for their members.

Without a comprehensive, Coordination of Benefits program, the health plan ended up paying inappropriate claims for its Medicaid members. When a primary coverage source was later discovered, the plan incurred the administrative expense of attempting retroactive recovery. In many cases, the error was never discovered.

The health plan realized it needed better access to eligibility data, and decided to pilot a more comprehensive strategy.

The Solution: Identify Primary Payers

The health plan implemented a core component of Change Healthcare’s Coordination of Benefits solution, which identifies and reconciles improper billing to help ensure that Medicaid agencies remain the payer of last resort. The plan launched a pilot program in four states to determine its members’ medical coverage using Change Healthcare’s Coordination of Benefits solution.

The Coordination of Benefits solution identifies a member’s payer of record using Change Healthcare’s unparalleled data repository of more than 1.9 billion commercial payer records. The plan uses a proprietary match algorithm to scan medical, pharmacy, dental, and vision eligibility information for each member’s primary payer.

“Change Healthcare’s Coordination of Benefits solution maximized our health savings and we couldn’t be happier.”

-Director of Payment Integrity at large health plan

The Results: Early Confirmation of Member Coverage Maximizes Cost Avoidance:

At the end of the first month, the health plan had realized an initial cost avoidance savings of $2.2 million. In 2019, the year-end cost avoidance savings for the Medicaid Coordination of Benefits Identification program was $73 million.

After achieving such impressive results in just four states, the health plan decided to broaden its solution rollout to include other states. In 2019, the health plan implemented full medical Coordination of Benefits programs in 20 states—pharmacy Coordination of Benefits programs in 15 states.

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