HMS Launches Coordination of Benefits on Demand Solution with Near Real-Time Insight into Other Coverage
March 25, 2021 at 08:00 AM EDT
IRVING, Texas, March 25, 2021 (GLOBE NEWSWIRE) -- HMS (NASDAQ: HMSY), a leading provider of payment accuracy and population health management solutions, has launched a Coordination of Benefits (COB) on Demand solution as part of its suite of industry-leading COB solutions. As healthcare continues to evolve, real-time eligibility solutions offer measurable value to COB programs. COB on Demand offers near real-time insight – starting day one of coverage – into whether Medicaid members have other existing third-party health insurance, ensuring the correct payer is billed for patient care.
According to HMS’ data, approximately 20% of Medicaid members have access to other healthcare coverage, but it is often difficult for health plans and providers to identify when this is the case, contributing to the $56 billion of improper Medicaid spending in 2019 alone. With COB on Demand, state Medicaid agencies and health plans can quickly identify all relevant coverage at the point of enrollment or prior authorization, helping to preserve the integrity of Medicaid as a payer of last resort and significantly reducing costs and administrative burdens for both payers and providers.
Amid the current health crisis and with Medicaid enrollment on the rise, ensuring the fiscal integrity of public health and safety-net programs is especially critical as state Medicaid agencies grapple with budget deficits brought about by the pandemic. Additionally, agencies can leverage COB on Demand to validate high-cost claims, as well as claims related to COVID testing and vaccinations.
“The coordination of patient benefits is critically important to the success of the American healthcare system, especially as safety-net programs like Medicaid are experiencing enrollment surges due to the COVID-19 pandemic,” said Michele Carpenter, SVP Government Services for HMS. “Identifying which patients have coverage through multiple health plans is a huge administrative burden for payers and providers alike and can cause patients to be billed incorrectly. With COB on Demand, Medicaid agencies and health plans can rapidly identify when a patient has coverage through a third-party plan other than Medicaid, reducing administrative hurdles and ensuring providers are reimbursed correctly.”
Third-party liability (TPL) laws and regulations are designed to ensure that Medicaid is the payer of last resort, which means that for the approximately 7.6 million Medicaid enrollees who have access to coverage from a third-party carrier, that third-party is required to pay all or part of a member’s medical care expenses before Medicaid pays. By identifying third-party coverage at the point of enrollment or during prior authorization, COB on Demand moves typical cost avoidance (CAV) upstream, helping providers avoid pay-and-chase activities and reducing administrative burdens. With 24-hour turn-around time, COB on Demand increases typical CAV performance by up to 15%.
HMS’ COB on Demand solution uses machine learning algorithms, advanced matching logic, application programming interface (API) technology, and rapid batch processing to proactively identify, verify and communicate existing third-party coverage before billing in near real-time from day one of coverage. The proprietary solution is designed for secondary payer and payer of last resort programs including Medicaid, the Children’s Health Insurance Program (CHIP), and the AIDS Drug Assistance Program. COB on Demand can be implemented as an API, Secure File Transfer Protocol (SFTP), or user interface portal and facilitates interoperability with Medicaid Enterprise Systems and other enrollment and claims management systems.
To date, COB on Demand has seven deployments spanning multiple Medicaid agencies, state and federal healthcare exchanges, and Departments of Health providing accurate and rapid healthcare coverage identification for the millions of consumers they serve.
After deploying COB on Demand, the state of New Mexico received over 75,000 new enrollees in seven months and, during that time, identified 92% of TPL at enrollment. The early identification provided by COB on Demand will save New Mexico more than $2.2M in annual savings.