COB Curation: Real-time Coordination of Benefit Automation and Correction

POSTED March 01, 2023

By David Figueredo, Chief Operating Officer

According to a 2020 Kaiser Foundation study, 17% of claims are denied with 50% of providers in the southeast and mid-west experiencing 20-30% denials rates according to CMS Transparency data published in 2021. While denials can be the result of a wide range of procedural and informational issues,

a prevalent theme as one looks at the data is that nearly 50% of denials can be associated with registration and coordination of benefit reason categories.

In the idealized world payers believe providers should operate in, a patient is registered weeks prior to their schedule preventative services episode of care. During that registration process, the patient freely informed the provider of their insurance, being sure to communicate their comprehensive and complete set of insurance profiles. Every Medicare patient knows they have Medicare Advantage and provide their insurance policy number and complete demographic information set for that, their Medicare supplemental policy and Medicaid tertiary coverage, which are all perfectly entered in their EMR and verified in real time.

The reality is that most patients do not fully understand the myriad of commercial and governments entities involved in providing coverage. They typically do not carry copies of all their insurance cards, nor would they provide each to their provider at the point of scheduling appointments. Registration staff are over utilized and typically don’t fully understand enough to ask guiding questions the patient that would uncover additional insurances and many registration workflows are fortunate enough if they even ask the patient for secondary insurance.

Compounding that are the issues with payers who, due to informational firewalls that exist, may not even be aware of the existence of other responsible parties at the time of service. their system may contain outdated third-party liability information which can miss inform providers and lead to erroneous claim denials. Even when a commonly informed entity, like Medicare and Medicaid, provide pointers to other insurance like managed care plans or Medicare Advantage programs, they seldom provide complete insurance data or policy details sufficient to allow the registration staff to take action… if they had noticed in the first place.

Wave HDC’s COB Curation solution is integrated directly in the eligibility verification process, integrating seamlessly to the registration and scheduling workflows. Leveraging Wave Analyzer an extensive background in eligibility, Wave’s technology automatically analyzes each payer response in real-time at the point of processing to identify hidden cues to other insurance that your systems and staff cannot see. Once identified our system does not just alert the user of the existence of other insurance, it automatically triggers additional inquiries to those third-party entities to verify the active and billable coverages and to collect and curate a comprehensive insurance profile. These secondary payer responses are further interrogated to identify additional cues to additionally surveil and curate.

This dynamic automation process coupled with Wave’s best in class identity confidence scoring and primacy engines is the Wave difference. When all insurances have been exhaustively discovered, each resulting policy is systematically evaluated for identity risk profiling using our advanced identity engine which flags potential risk policies for manual review while allowing high confidence low risk coverages to auto postto the HIS or host system to eliminate operator error. Wave understands that each provider organization’s compliance department may have differing opinions as to how risk is measured and under what conditions coverage should be allowed to be posted to a patient profile, therefore our implementation team works with each client operations and compliance team to codify, build and verify all identity and compliance logic prior to go-live, there by allowing higher levels of automation with lower risk profiles than any other solution on the market today.

With a comprehensive set of insurances comes in additional problem, that of understanding which insurances are actionable versus informational. Wave Analyzer’s primacy engine interrogates each policy to determine its type of coverage and other important details that allow the system to categorically determine the primacy order for each policy. Additionally, by systematically identifying the patient’s primary, secondary and tertiary insurance’s’, the system can mark and even suppress informational and non-billable coverages. With a comprehensive understanding of advanced primacy rules, our engine eliminates the guessing game and increases billing accuracy by automatically identifying and categorizing coverages in real-time. If you don’t have Wave, you have a team of people doing this, and unfortunately, it’s inconsistent.

This systematic automation approach to insurance verification leads to a more comprehensive insurance profile for each episode of care. As such, our technology is able to identify corrected primary coverages, undocumented MCO and Medicare Advantage changes and even discover unknown secondary and tertiary coverages at the time when that information is the most urgently needed, at the point of care. This leads to more accurate registrations and good faith estimates, remediates issues within the authorization cycle stemming from authorizing with the wrong entity, and significantly reduces coordination of benefits denials by resolving the issue at the perimeter of your revenue cycle process, rather than during the claim denial management process.

In one deployment study for a large, multistate practice, Wave’s automation COB curation was integrated directly into the real-time insurance verification process at the time of patient onboarding and led to the realization that the system was provided corrected primary coverage for 12% of patient registrations and identifying undocumented Medicare supplemental and Medicaid secondary coverages for 6% of registration! If you use a registration QA tool, it’s NOT catching these errors. These errors are caught on the front exclusively by the Wave Analyzer, or when your denial management team is alerted, and then worked manually.

In another large health system deployment, the process was applied to the claim denial management process in which all primary payer COB denials were process prior to staff assignment. The Wave Analyzer was able to identify COB corrections and obtain the actionable information for 92% of all COB denials. Of these claims, >60% of claims were able to be refiled to the corrected primary payer immediately while the remainder required payer and patient outreach as the Wave Analyzer found evidence of inaccurate\outdated TPL records stored in the payer claim adjudication system that required correction.

Your organization relies on accurate data, you need Wave HDC.

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