Large National Health Plan Achieves $200M in Medical Cost Reduction with COB Smart

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CASE STUDY

Large National Health Plan Achieves $200M in Medical Cost Reduction with COB Smart

EXECUTIVE SUMMARY

One of the nation’s largest health plans decreased administrative costs by more than $50 million annually and increased medical cost savings by $200 million for its commercial, Medicaid and Medicare Advantage business lines.

THE CHALLENGE

A large national health plan with multiple lines of business, knew they had a great opportunity to benefit from coordinating benefits with other payers. However, each line of business presented a different challenge, requiring a patchwork of outside vendors, multiple sources of data which varied greatly in quality, and considerable manual intervention. They sought a more efficient process that would enable them to identify and process COB data more quickly and with less administrative cost.

THE SOLUTION

The plan began using COB Smart for their commercial, Medicaid, and Medicare Advantage lines of business. When they receive the COB Smart file each week, they autoload all validated data into their claims system and automatically set a COB flag so any claim that comes in for that member is processed as secondary. Their team then manually investigates any overlaps that did not pass validation, setting COB flags for those members after they have confirmed the information, or cleaning up their system if validation found an error. In addition, they have granted COB Smart portal access to numerous teams across the organization including COB Operations, Claim Operations, Pre-Pay and High Dollar Audit Operations, and Recovery Operations. These teams use the portal to quickly investigate member coverage and identify COB scenarios.

THE RESULTS
ROI for commercial business lines
60:1
ROI for Medicaid business lines
70:1
ROI for Medicare Advantage business
45:1
Increase in prospective savings
25%

The plan has seen numerous benefits from using COB Smart across all three lines of business. Their ability to autoload and to pay claims correctly initially has increased their medical cost savings, reduced claim rework, reduced vendor fees, and improved their member and provider experience. As a result, they have achieved a 60:1 ROI for their commercial business, 70:1 for their Medicaid business, and 45:1 for their Medicare Advantage business.

The data validation service has had a significant impact on their ability to process COB data quickly. An internal audit of validated data found that these records were accurate > 99.5% of the time. Because the quality is so high, these records no longer require any phone calls, member letters, claim rework, or help from other vendors or clearinghouses, a savings of almost $50M annually. Since going live with data validation, the plan has been able to autoload 25% more COB flags and increased their prospective savings by 25% by identifying COB flags sooner. By setting 265,000 new COB flags and processing 850,000 claims correctly as a secondary payer, the plan saw $200M in medical cost reduction. In addition, 29 staff members now have more time to work additional data they could not capture before, resulting in additional savings. According to the COB team, “COB Smart has the highest ROI out of all of our COB processes.”

Learn more about COB Smart. 

COB Smart has the highest ROI out of all of our COB processes.