By Jason Moseley, Senior Manager, Solution Consulting & Design, CAQH
In the rapidly evolving healthcare industry, managing third-party liability (TPL) data presents a significant challenge. Eligibility data can change hourly, making it difficult to share accurate information promptly. But doing it well is crucial to cost avoidance and accurately coordinating benefits.
Coordination of Benefits (COB) is one of the most complex claims processing functions within a health plan for several reasons. It involves multiple insurers with varying rules, requires accurate and timely data sharing which can be hindered by privacy concerns and incompatible systems. It’s also error prone and often leads to disputes between insurers resulting in confusion and abrasion for members and providers.
Health plans that have strong COB processes are not only able to recover incorrect claims payments but can cost avoid as well. Cost avoidance in healthcare is an essential strategy to reduce costs and administrative burdens because it assures claims are processed and reimbursed in the correct payer order. This strengthens member satisfaction and ensures compliance with legal and regulatory requirements.
To successfully cost avoid and address many other COB challenges, health plans should consider these best practices when working with TPL data:
- Synchronize Third-Party Liability Data Across Adjudication Platforms
Most health plans operate multiple adjudication platforms, especially those managing diverse types of claims such as medical, dental, and vision. For instance, a Medicaid payer may not process all claims within the same system. Therefore, creating an enterprise-level repository for TPL data is essential. This repository can efficiently disseminate records to the appropriate claims adjudication platforms, subsidiaries, or vendors based on eligibility and benefits.
By lifting the TPL process above Medicaid Management Information Systems (MMIS) to an enterprise level, health plans can consolidate all adjudications and receive all relevant files—whether from vendors, states, or other health plans—in one place. The challenge lies in integrating this information, cleaning it, and then distributing it to educate clients and inform the system. This comprehensive approach reduces waste and excess by reducing the number of man hours necessary to maintain TPL data, as well as minimizing incorrect billing submissions ensuring claims are submitted in the correct payer order.
- Reduce Vendor Spend While Increasing Data Quality
Aim to set up a hierarchical ingestion process to obtain high-value data at a low cost. Doing this requires a technological investment, but the cost-benefit of improved data quality justifies this expenditure. By examining your vendor stack and per-member costs, you can identify opportunities to optimize data feeds. For instance, synchronizing the timing of data feeds from different vendors can improve the quality and cost-efficiency of your TPL data.
Staggering and staging data based on quality and cost can lead to significant savings. Although auditing processes within MMIS may not always be robust, investing time in analyzing TPL data can yield insights that prevent costly manual interventions. By prioritizing high-quality data, health plans can reduce manual resource use and enhance cost avoidance savings.
- Prevent Unvalidated TPL Data from Overwriting Curated Records
A common issue in TPL data management is the overwriting of manually curated records with unvalidated data feeds. If a team member manually inputs data after validating it directly with another plan or clearing house, and then unvalidated data feeds from states or vendors overwrites this good data, it causes inefficiencies and errors. What’s more, plans often pay per update which results in unneeded expenditures.
If payers configure a warranty period on manual updates, this can protect the integrity of curated records and avoid the cycle of unnecessary updates and corrections. This approach not only saves time and money but also reduces member and provider abrasion, enhancing overall satisfaction and minimizes the drain on team members.
Managing TPL data effectively and driving cost avoidance is key to improving claims processing and overall health plan operations. By synchronizing TPL data across platforms, reducing vendor costs while increasing data quality, and protecting curated records from being overwritten by unvalidated data, health plans can enhance accuracy, reduce costs, and improve satisfaction for members and providers.
To learn more about these strategies and explore other innovative solutions, join us at CAQH Connect 2024.