How Innovation in Patient Matching Can Improve Coordination of Benefits

By HMS
Aug. 29, 2019

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The healthcare revenue cycle relies heavily on patient identity management (PIM) — broadly, the ability to match patients with their health records across various systems and throughout their lives. Without a universal identifier, however, PIM remains more of an ideal state than a current practice. This is especially relevant with regard to the exchange of healthcare data across organizations — a capability that is fundamental to the coordination of benefits and care among stakeholders.

Patient identification is perhaps one of the biggest issues in healthcare today. Not only are data matching errors potentially harmful to patients, but they contribute substantially to administrative burden at the payer and provider level and cost the healthcare system billions of dollars annually. A recent survey from Black Book found that inaccurate patient identification or information was responsible for an estimated 33 percent of denied claims in 2017 — a cost of $1.5 million a year to the average hospital and more than $6 billion a year to the healthcare system as a whole.

Advances in health information technology and organizational best practices are helping to reduce patient matching errors within the walls of healthcare organizations. However, as the industry shifts toward a more whole-person, coordinated care approach — wherein various stakeholders must be able to collaborate and share information seamlessly — mechanisms for cross-organizational data exchange are becoming increasingly critical. And though this capability is a principal focus for health technology innovators, the larger issue lies in the inherent ambiguity of patient demographic data — and a lack of interoperable systems to help reconcile information gaps.

Coordination of benefits (COB) is one example of how insufficient data collection methods, combined with ineffective matching systems, can create inefficiencies throughout the healthcare system. Here, we’re exploring how advances in patient matching can reduce COB errors and improve the continuum of care.

Integrating Patient Matching Technology Into the COB Process

When an individual has more than one source of health coverage, COB and third-party liability rules determine which payer has primary payment responsibility and the percentage that others must contribute. But when it comes to how we obtain the data that informs this distribution of payment, things aren’t always as straightforward.

One common example we see is when an individual has Medicaid in addition to other public or commercial health coverage but neglects to report third-party payers. If the discrepancy isn’t caught prior to submitting a claim, the claim will likely be denied, necessitating extensive rework and prolonging the revenue collection process. If, on the other hand, we were able to gain a comprehensive view of the individual’s coverage data across various organizations and plan types — and if we had this information prior to the point of service or billing — we could substantially reduce the administrative burden associated with claim denials.

Next-Generation Data Collection & Matching

While there are clear advantages to utilizing patient matching systems as part of the COB process, there is a thin line between benefit and risk. Relying on limited data networks and error-prone phishing techniques can result in false positives and low match rates, rendering these methods ineffective at best — or worse, non-compliant.

To be successful, patient matching technologies must draw on a vast, reliable and continuously-updated data source, while applying advanced analytics to ensure consistently accurate matching of coverage data to the correct individual. But more than that, these technologies must be implemented as part of a comprehensive COB program — one that addresses the full healthcare continuum to not only maximize cost avoidance for payers and providers, but to facilitate better coordination of care for patients, especially those who rely on government-subsidized health coverage.

A Proactive Approach

When it comes to identifying third-party liability, solutions that are able to prioritize cost avoidance in addition to post-pay recovery are yielding the greatest results. The industry’s most leading-edge COB solutions are allowing payers and providers to understand the full scope of medical, pharmacy, dental, vision and other relevant coverage prior to an individual even entering the clinical setting, enabling right-first-time billing and ensuring accurate billing for future instances of care.

COB is a prime example of how the efficient, secure and accurate exchange of patient health information across systems and stakeholders is critical to reducing healthcare spending and improving the coordination of care. How are you ensuring proper coordination of benefits within your organization?

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