CASE STUDY

The Challenge

A mid-sized Medicare Advantage (MA) plan was missing out on revenue due to misaligned Medicare Secondary Payer (MSP) designations with Centers for Medicare and Medicaid Services (CMS). In some cases, commercial payers were listed as primary even though the MA plan was financially responsible for care. This reduced the monthly capitation payments the plan received by as much as 70 percent for affected members.

This issue stems from the complexity of coordinating benefits data across the healthcare ecosystem. Because COB data is often reported inconsistently and can quickly become outdated, MA plans and CMS alike face challenges in ensuring primacy is correctly assigned. Although the plan was aware of the issue, they lacked a streamlined, scalable way to identify and correct discrepancies. Manual efforts like payer calls were time consuming and often failed to address the growing backlog of underpayments.

The Solution

The plan partnered with CAQH to implement a targeted, data-driven strategy to identify and resolve inaccurate MSP designation, ensuring appropriate capitated monthly payments moving forward.

The CAQH COB Solution hosts eligibility information for more than 225 million covered lives. The plan cross-referenced this data with their historical membership and MSP records to detect errors and secure appropriate capitation payments. This approach uncovered millions in previously underpaid capitation payments while also improving prospective accuracy.

By leveraging accurate COB data, the plan was able to realize immediate and ongoing returns to:

• Identify and adjust millions in retrospective revenue
• Reduce costly manual verifications
• Accelerate retrospective adjustments and correct prospective payments

This strategy gave the plan greater visibility into which members were most likely to yield recoveries, allowing them to clear a multi-year backlog and prevent future missed revenue.