Epic helps, but COB denial trends persist. Learn how hospital revenue cycle leaders can partner to resolve COB issues, improve patient financial experience, and protect revenue.
Epic and competing EHR systems play a key role in reducing Coordination of Benefits (COB) denials. Many hospitals and health systems rely on these technologies to identify missing data and perform real-time eligibility checks when a patient has multiple health insurance plans, thereby reducing the risk of claims being billed to the wrong payer or in the incorrect order. The technology provides a crucial foundation for managing COB complexity and reducing reimbursement delays by facilitating data exchange and streamlining workflows between providers and payers.
However, Epic and other EHRs aren’t enough to effectively address COB denials and protect revenue. COB denials may still occur because EHRs do not enforce payer compliance, nor do they account for all the variables that can affect a complete and accurate picture of payer responsibility, particularly when information gaps require information held by the patient. Thus, this area of revenue cycle can be particularly challenging and time-consuming for hospital revenue cycle executives tasked with lowering denial rates and accelerating reimbursement.
Will Epic Fix Hospitals' COB Denial Pain? What You Need to Know
Epic does a lot to streamline COB processes, but it can’t fully eliminate denials on its own. Several reasons include:
Dependence on payer data. Epic can only process what it receives. If payers have outdated or inaccurate primary/secondary coverage information, Epic can’t always reconcile that automatically. Also, some payers don’t respond in real time to eligibility queries, leaving gaps.
Complex coverage scenarios. Accident-related coverage, such as MVA or workers’ comp-associated claims, can require data outside the patient record to resolve. Also, Medicare/Medicaid pose specific sequencing requirements (e.g., MSP [Medicare Secondary Payer]) that are nuanced and can change; Epic doesn’t automatically resolve those edge cases. Similarly, coordination with carve-outs or third-party administrators can present a challenge. For example, behavioral health and pharmacy benefits may sit outside Epic’s eligibility verification.
Patient-reported coverage gaps. Patients may not report new coverage, COB questionnaires may not be completed, or self-reported information may be inaccurate. Without proactive outreach, these missing details can cause Epic to bill the wrong payer first.
Limited automation for exception handling. Epic’s eligibility workflows are rules-driven but not as dynamic as specialized COB vendors. Denial-prone scenarios (e.g., overlapping coverage, divorce decrees affecting dependents, or retroactive Medicaid) can require manual intervention.
Timeliness of updates. Payers may retroactively update coordination rules or effective dates. By the time Epic has the corrected data, the claim may already have denied.
For hospital revenue cycle executives, these limitations underscore why Epic is necessary but not sufficient for preventing COB denials.
3 Tactics for Successful COB Denial Resolution and Managing Patient-Involvement Denials
Epic and competing EHRs can provide a strong foundation for resolving COB issues, applying eligibility checks, insurance sequencing rules, and claim edits. But the best strategy needs to be multifaceted and will often involve partnering.
Hospital revenue cycle executives who want to reduce COB denials and improve the patient financial experience should consider working with a COB resolution partner that provides additional tools and expertise. A successful approach should include the following three tactics:
1) Leverage the right COB resolution technology
Seek an insurance discovery partner that sweeps for missed coverage. Coverage status and rules change frequently, and payers may sometimes apply outdated information. Reliance on the patient also presents vulnerabilities, as noted.
Therefore, revenue cycle executives need access to systems that will comprehensively identify new and previously unknown coverage and verify existing information relating to layered coverage. COB partners with advanced insurance discovery technology have access to external data sources, payer databases, and verification tools that go beyond what the hospital can reach internally. Modern COB resolution partners use the latest tools in unidentified insurance discovery and workflows to speed processes and minimize the need for patient involvement.
2) Appreciate the difference that experience brings
Technology alone isn’t enough. The team working these accounts will also need expertise specific to MVA, workers’ comp, and other coverage scenarios that often require investigation. Auto accidents, workers’ comp, and liability cases can be time-consuming to resolve. Also, they will often trigger COB flags across all related claims—even when a later visit is unrelated to the original accident. For example, in the weeks following an auto accident, COB denials may occur when a patient receives a tonsillectomy or other clearly unconnected service.
Partners with expertise and dedicated workflows for managing these sometimes-complex scenarios will be most efficient. Dedicated teams in these areas know the proper information to document, how to best complete and route information to align with payer preferences, and ways to best address patient concerns. Such expertise often makes the difference between resolution occurring in one call versus several.
3) Recognize patient-involvement denials often demand a different level of focus and service support
Healthcare providers must do more than accurately verify patient insurance information and ensure all necessary COB details are recorded in the EHR during registration. They also need to have a plan in place for when COB delays and denials occur, especially those that require patient involvement. As such, the right COB and patient-involvement denial management strategy needs to support the human element in interventions. Positive patient experience supports have a profound impact on success, such as after-hours availability, web-based information submission capabilities, and even visits to the patient’s home when needed.
Patient communication preferences and information needs vary greatly. The ideal COB resolution partner will have tested letter templates and communication paths, as well as the ability to customize outreach—whether by email or possibly a text message that includes a link to a portal designed with payer-specific information, allowing the individual to complete or upload the necessary details. In situations where both claim value and outreach challenges warrant special attention, a field visit to the patient’s home can even be an option.
The COB resolution partner’s training and experience can also result in a more positive patient experience. The right person will be able to successfully guide a three-way call between patients and payers with efficiency by taking proactive measures to prevent potential issues, adjusting quickly as new information becomes available, and anticipating when additional details are required. Experienced partners can also quickly recognize when resolution can be achieved without the need to involve the patient.
Beyond Simply Reducing COB Denials and Patient-Involvement Denials
Epic and other EHR platforms provide a strong foundation for reducing COB denials, but hospital revenue cycle executives know that technology alone is not enough to protect reimbursement. COB denials and patient-involvement denials still occur when coverage is complex, payer data is inaccurate, or patients cannot easily provide the information needed. The most effective strategy pairs Epic’s core capabilities with a COB resolution partner who brings specialized expertise, advanced insurance discovery tools, and patient-friendly outreach. By working with the right resolution partner, hospitals and health systems can not only lower COB denial rates but also support a positive patient financial experience, accelerate cash flow, and improve revenue recovery.
To learn how Knowtion Health can improve your COB and patient-involvement denial strategy, contact services@knowtionhealth.com.
