Cotiviti, a healthcare infrastructure company, launched a new AI-powered coordination of benefits solution on Thursday to support payers.
Salt Lake City-based Cotiviti offers solutions to increase transparency and collaboration between payers and providers. The new solution, called Proactive COB, is meant to support payers and providers at the time of member enrollment.
Coordination of benefits is the process insurance companies use to determine how to cover medical expenses when a person is covered by more than one health plan. It determines who pays what by understanding which plan is the primary payer and which is the secondary. Errors with coordination of benefits typically occur when a member changes coverage due to life changes like switching jobs, retiring, getting married or having a baby.
“Any of those changes can change the order of the benefits,” said Matthew Herbein, vice president of product at Cotiviti, in an interview. “What that means is, if you go to a healthcare provider and you have multiple health insurances, well, that provider has to kind of understand which one to bill as primary, and then which one to maybe bill as secondary to cover your member responsibility. The issue at hand is that data is very fragmented.”
When people enroll in new coverage, health plans often don’t receive complete or accurate coverage information. Therefore, errors can go undetected until after claims are paid, leading to costly recovery efforts and added administrative work.
Cotiviti’s Proactive COB addresses these issues by identifying and validating when a member has other health insurance and determining the correct order in which benefits should be paid. It relies on member enrollment data rather than waiting for a medical claim to be submitted to identify coordination of benefits issues.
“Today, coordination of benefits is done once a claim comes in, once you or a family member goes to the doctor,” Herbein said. “[Proactive COB is] actually a claim-agnostic coordination of benefits capability that identifies other health insurance and correctly identifies the correct order of benefits at enrollment. Nobody else in the industry is actually doing it as early as enrollment.”
The company is currently piloting the Proactive COB solution, and plans to have it become generally available in the first quarter of next year, according to Herbein.
To track the solution’s success in the pilot phase, the company is focused on cost avoidance — reducing administrative waste from misrouted claims — while also monitoring how often it correctly changes the order of benefits, the per-member-per-year impact and how smoothly the solution integrates with health plans, Herbein said.
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