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Case Study

How a Regional Plan Reduced Outbound COB Calls by 65% in Six Months

 

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The Challenge

A regional health plan serving over 1.2 million members faced ongoing challenges in managing its coordination of benefits (COB) process. Seeking a more streamlined and modernized COB approach, the health plan implemented the CAQH Coordination of Benefits (COB) Solution to improve its processes.
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Inefficient Manual Processes

Most COB investigations were conducted through time consuming outbound calls to members or other payers. These calls often went unanswered or resulted in long hold times.

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Costly Recoveries

After low member response rates, the plan turned to recovery vendors. Recovery activities are costly due to high fees
associated with these vendors, and they can be burdensome for both members and providers.

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Low Response Rates

When outbound calls were unsuccessful, the team relied on sending survey letters to members. COB letters are costly and returned limited responses, many of which were incomplete or missing key information.

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Member Frustration

With no way to independently verify COB information, the burden fell on members to self-report. Relying on sources like member surveys or phone calls after reported coverage errors is ineffective for plans and frustrating for members.

The Solution

After conducting an internal analysis, the payer began using the CAQH Coordination of Benefits Solution and the Member Data Portal to streamline and automate its verification process. With access to a centralized repository of validated COB coverage information for more than 235 million members on a weekly basis, the health plan’s COB team was able to efficiently identify overlapping coverage without relying on member input or claims investigations.

This shift allowed them to move away from a manual, member-dependent process to an automated, data-driven approach. Additionally, the Member Data Portal provided quick access to coverage overlaps, direct contact information for other health plans, and more effective resolution of coordination issues.

The Results

After implementing the CAQH COB Solution and Member Data Portal, the health plan achieved measurable improvements:
65 %

reduction

in time-consuming outbound calls to verify coverage in the first six months

1.5

business days

average for COB resolutions that previously took weeks

11 %

reduction

in external findings within six months

Looking Ahead

As the health plan continues to automate COB processes and further integrate the CAQH COB Solution into its operations, it anticipates even greater efficiencies and savings. The solution has already demonstrated its ability to simplify COB management, enhance member satisfaction, and reduce operational burdens.

 

By reducing reliance on manual processes and improving the speed and accuracy of COB determinations, the organization is better positioned to manage costs and deliver a superior member experience.

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