Most COB and patient involvement denials go unresolved. Learn how hospitals and health systems can strengthen back-end strategies to recover missed revenue and improve patient satisfaction.
All too often, revenue cycle leaders tackle COB denials and other patient-involvement issues with a single mindset: Build strong verification workflows and patient engagement scripts upfront to capture all secondary insurance details at registration — and then little more.
That’s because many leaders mistakenly view this category as not worth the chase relative to other denial types. After all, COB and patient information issues often involve multiple payers, the dollar amounts per claim may be small, and the effort-to-yield ratio looks less attractive when compared with clinical or medical necessity denials. Therefore, revenue cycle executives may allocate staff time to denial types that are easier to automate or resolve at scale.
Yet such beliefs result in missing out on considerable revenue. "About 65 percent of COB and patient information denials are rarely resolved,” notes Mikky Franklin, SVP of Revenue Cycle Management at Knowtion Health.
Generally, revenue recovery potential associated with these accounts equates to about 2 percent of the NPR for a typical health system, notes Franklin. A hands-off approach can also contribute to poor patient satisfaction, as often, payments that could have been recovered from insurers ultimately become the patient's burden.
What Does Better COB Denials Management Look Like? Strengthening Back-End Strategies
While COB denials and patient information gaps are often considered “front-end issues” (registration, eligibility, insurance capture), there are real back-end strategies that can make a measurable difference. Here’s what better management looks like, and where either back-end teams or, more often, specialized service partners can step up a hospital or health system’s success:
Employ Comprehensive Technology
Insurance discovery tools vary. Hospitals and health systems should continually invest in or contract with service partners who can most comprehensively search commercial and government databases for hidden coverage, as policies covering dual-eligible populations and MVA-related information needs can be complex and change frequently.
Recognize How Expertise Affects Time to Resolution
Perhaps even more important is having the right team working these accounts. COB resolution often requires manual outreach to patients or secondary payers and repeated claim submissions, which can consume a considerable amount of staff time. As such, successful revenue cycle leaders recognize the importance of establishing the right work queues for resolution and assigning the right team.
It’s essential not only to act on claims with high recovery potential or resolution probability before they age too long, but also to ensure they are assigned to specialized denial resolution staff. Whether it’s knowing payer communication preferences or the best escalation contact, the difference in an individual’s experience in this area can easily make the difference between resolving an issue in one call or multiple.
Effective COB management requires specialized payer knowledge, experience with effective workarounds, and a qualified, integrated team with specific and diverse skill sets—from billing to coding to patient advocacy to legal knowledge.
For instance, every payer contract contains an implied covenant of good faith and fair dealing. A revenue cycle specialist with legal knowledge will be able to recognize scenarios where a denial is based on an unfounded reason to not pay, such as when health plans rely on timely filing rules in unjustifiable circumstances. An expert on COB workarounds, meanwhile, can quickly ascertain whether a COB denial can be resolved without the patient’s involvement, such as when the payer requests more information for an accident claim, but the accident is an injury that did not involve a third-party liability carrier, for example, a finger cut in the kitchen.
Design Your COB Denials Approach Around the Patient Experience
COB and patient information issues aren’t one-size-fits-all. Not only does the information required from the patient vary, but so does the patient’s ability to respond to these requests. Patients may be unsure about how to respond to an information request or be discouraged by the inconvenience.
The right communication solutions are therefore imperative. Busy patients may be more responsive when given access to options such as after-hours availability or the ability to upload information to a portal.
Specialists will often guide three-way calls with the patient and the payer to remove potential bottlenecks to resolution. In certain instances, even having a COB specialist visit the patient’s home may be important for success.
Here, too, partnering with a service partner can make a significant difference in supporting these capabilities.
Quantify COB and Patient Information Denials Revenue Recovery Potential
Coordination of Benefits (COB) denials are an ongoing source of revenue leak at many hospitals and health systems, but they don’t have to be. One of the first steps to pursuing back-end improvement options is quantifying the revenue recovery opportunity. Examining common CARC codes many payers use to deny claims for COB or other patient information requests, along with a breakdown of CARC 16 (a common catchall code) into RARCs commonly associated with these types of denials can make it easier to recognize revenue recovery potential.
To learn more about how Knowtion Health can help you conduct this analysis and its COB and patient involvement denial resolution services, contact Services@KnowtionHealth.com.
