COB Smart: Health Plan Strategies on Coordination of Benefits
Table of Contents
- Welcome to today's program titled health plan strategies on coordination of...
- Providers that are serving that member it's a pretty simple concept but one...
- Team was implemented to start doing the co B investigation specifically we were...
- The the challenges here I think that are worth calling out well when of service...
- Million plus since the inception we've identified closer to 15 million in Co B...
- We have not well I'm trying to understand this question correct place...
00:00
welcome to today's program titled health
plan strategies on coordination of
benefits saving money through efficiency
and collaboration at this time all
participants are in listen-only mode
later we will conduct the live
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00:31
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01:02
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please go back in on your telephone I
would now like to introduce our host for
today's call Jill Brown Ms Brown you may
begin thank you and welcome to the live
webinar health plan strategies on
coordination of benefits saving money
through efficiency and collaboration
which is hosted by CA to H I'm Jill
Brown executive editor of AIS and I'll
serve as the moderator for our
01:32
discussion today like to introduce our
speakers for today's webinar and brisk
is a director at C iqh and leads the
sales team focused on offering
innovative solutions to the healthcare
industry that helped reduce
administrative costs she has over 20
years of experience in financial
services payments and health care
Kristina Welch's coordination of
benefits investigator at Blue Cross Blue
Shield of North Carolina in her role
kristina initiated the health plans
02:03
end-user implementation of the caq h CEO
be smart projects beginning in december
2013
and Shawn Killeen is executive director
of claims payment integrity and cost
containment at Kaiser Permanente and
Kaiser Foundation health plan aims
Shawna's responsible for providing
leadership and strategic directions for
Kaiser Permanente's claims payment
integrity cost containment operations
which includes code editing clinical
review coordination of benefits and
other peri liabilities and recovery
02:36
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03:07
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our webinar here is an risk great Thank
You Jill so I'm gonna start out all
right let me take control okay I got it
okay I'm going to start out by talking a
little bit more about CA QH for those of
you that are not familiar with our
organization so first of all we are a
very unique and different type of
03:39
organization that helps bring the
industry together to collaborate on ways
to lower administrative costs and we are
actually a non-profit alliance
we're actually made up of health plans
that help determine the types of things
that they would like to focus on in
order to reduce cost across the industry
for payers providers and ultimately for
patients and members as well we do have
a number of different solutions that we
offer in the market that are focused on
reducing administrative cost so we're
going to talk more about Co be smart
04:08
today enroll hub is actually a solution
that helps providers enroll with
multiple payers to replace checks with
ACH payments so we're simply trying to
make it easier for providers to be able
to switch to a CH and
help lower costs that are associated
with paper checks in addition we have
been operating for a long time a
solution called CA qh pro view which
essentially helps to gather all of the
background information about all
different types of providers across the
industry in one place to help make it
04:40
easy for all the different organizations
that need to contract with them to
access that data on a regular basis that
solution has been around for more than
10 years and has a very significant
portion of the industry using it to to
access background information along with
that we do have a solution called
sanctions track that does help to track
basically industry sanctions that have
been applied to providers and helps the
organizations that work with them
monitor those as they provide access to
05:10
that to that community and then many of
you may be familiar with CA qh cor CA qh
core is essentially bringing the
industry together to help set operating
rules to help everyone become more
efficient at actually interacting and
using administrative transactions with
each other so c HQ h cor does have a
number of industry workgroups which a
lot of providers vendors and health
plans all participate in to help drive
those rules and again it's probably one
05:43
of the better parts are more well-known
parts of CA qh as well and finally we do
also have an index that's available on
the CA qh website that help to benchmark
the adoption of electronic transactions
and if you're interested in looking at
sort of where the adoption sits across
the industry that's a great resource for
you as well ok so now I'd like to talk a
little bit about why collaborate in the
healthcare industry and that's really
06:14
what CA qh is all about there are many
many repetitive processes in healthcare
for both payers and providers they
frequently need to share information
over and over again and this uses very
valuable resources that could be better
spent frankly on patients and members
what is unique about our approach is
that providers typically do not actually
pay too
solutions that CA qh has however they do
benefit greatly from from participating
in these types of solutions health plans
and other types of organizations that
06:45
are accessing our data and using these
solutions do help fund did the use of
them and and that basically helps lower
cost for everyone across the industry
and that's really what's what CA qh is
all about is kind of bringing both sides
together just to drive out some of the
simple processes that make up a lot of
the day-to-day business so let's talk a
little bit more about what what
coordination of benefits actually is we
07:16
use a term Co B and that actually does
refer to essentially health plans having
to coordinate benefits for claims
payments the industry spends a lot of
time and money on making sure that we
pay claims correctly when a patient or a
member has two or more insurances than
this can get very messy because
typically neither the provider or the
health plan may be aware of that
information so CA qh is trying to
effectively eliminate the excess costs
that are related to not knowing who
07:47
those members are that do have other
forms of insurance and then being able
to properly assess who should pay a
claim so why are we doing this well
essentially Co B is a big problem in the
industry as we know that about 5% of all
healthcare membership actually has more
than one type of insurance yet this
simple problem drives up about eight
hundred million dollars in additional
administrative costs for payers and
providers these are not claimed dollars
08:17
this is actually just the cost
associated with submitting and paying
claims and then having to correct those
mistakes when it's not done right these
costs are generally split roughly 50/50
between payers and providers so
providers are obviously trying to chase
down their money
payers are trying to ascertain if
they're the right payer and a lot of
time and energy gets spent correcting
the problem after the fact if it is paid
incorrectly so this is a big problem and
it's one that really by bringing
collaboration to the table
08:48
we have the ability to actually solve so
we decided to tackle this problem
head-on and ultimately actually attempt
to eliminate the problem so Co be smart
really is the industry coming together
to identify health health plan
membership that has overlapping coverage
determine who should actually pay first
when there is more than one form of
coverage and then share that information
with the two health plans that have that
particular member as well as the
09:20
providers that are serving that member
it's a pretty simple concept but one
that that by bringing the industry
together we can actually make work so
let's talk a little bit about how it
actually works first of all we have
health plans submitting all of their
membership information and coverage data
every single week to see aqh we think
it's important to get the data weekly
simply because there are changes that
constantly happen some of those changes
09:50
can be retroactive so we want to make
sure that everyone has the most
up-to-date information as it continues
to change throughout the year
CA qh matches the demographic
information down to the dependent level
to actually find overlapping coverage we
then use the National Association of
Insurance Commissioners rules to
determine who should pay first and why
so the industry has essentially already
determined basically for all types of
coverage who the first and second payer
10:21
should be in those situations and we're
applying those rules to make sure that
we can indicate that when we send back
this information and then finally we
send back the subset of every health
plans membership that has overlapping
coverage along with the primacy
information to all of the participating
plans each week so data gets typically
gets submitted on a Monday and then the
following Monday everyone gets their
data back so what does the what does
10:53
each plan actually receive so basically
they get all of as I said a subset of
their members that do have overlapping
coverage
and again they get that on a weekly
basis so they have the most accurate
information to process a claim they will
receive information about the other
health plan and the coverage information
for that plan as well and then finally
we do include the indication of primacy
if we were able to determine it and even
if we were not able to determine it
based on the data that we received we
11:23
will indicate why we were not able to
determine it so basically every health
plan is going to have that subset that
represents it does have other coverage
with the health plan and the information
that that would be needed to actually
submit that claim properly to the other
health plan plans can then include that
information in the eligibility response
that they give to providers so now plans
have the most accurate information to be
able to actually tell a provider if they
do submit a claim incorrectly who the
11:53
proper payer should actually be so Co
b-smart has been producing results for
the industry for almost two years now we
introduced this back in late 2013 we
currently have 18 plans that are
representing over 140 million members
across the u.s. with all types of
insurance in addition we are working
with the nation's leading clearinghouses
to ensure that providers can start
receiving this information when they
submit a 270 eligibility request so if a
12:26
provider is submitting it and there's a
participating plan that that is part of
Co be smart we are actually working with
those clearing houses to be able to
access that data and then make sure that
that provider is getting that
information back this is ultimately how
we will solve for the problem of helping
the provider to submit the claim right
the first time I'd like to share a
little more information about what we're
seeing in general across this very large
population of membership from a co B
12:56
perspective first of all I want to show
you basically what makes up the bulk of
that hundred and forty million members
that's represented in the co B database
so we are actually building the
industry's first national database of
commercial insurance
it's available to all types of health
insurance companies and that does
include both fully insured and and ASO
or self-insured business for companies
and again this is the first time that
this type of data has been put together
13:28
to allow the plans that have to process
these claims access to it on a weekly
basis one interesting stat and I think
something that surprised many of the
participating plans is that we have
determined that roughly a third of all
membership all health plan membership
actually lives outside of their contract
state so that has led us to understand
that it is critical to have a national
database to look for coverage there are
13:59
many of us that work for organizations
and obtain insurance through that
organization that's actually located in
another state or another market but then
we in fact live in another another part
of the country so if you are looking for
Co B you do need a national database to
be able to find other types of insurance
for individuals some other interesting
stats that we're seeing is that again
this is basically the first time we
found that the industry can kind of
speak to what the actual rate of
14:30
overlaps is for membership and we're
finding in general that on average it's
about 5% of all health plan membership
as you can see that does vary by the by
the types of insurance so it's about
five and a half percent for commercial
group insurance 4.3 percent for
individual insurance and that we think
could continue to obviously to grow as
individual insurance grows about four
and a half percent for Medicaid MCO
business and then just about 2.3 percent
15:00
for Medicare Advantage so definitely a
range depending on the line of business
but again in general on average we're
seeing just about 5% across the entire
industry we're also finding about 12% of
all overlaps are actually internal to
our health plans so that means we're
helping the plans identify overlaps even
within all of their own insurance
coverage to help them better process
claims between those plans
and then finally in general we still see
15:31
that as we continue to find more
information about overlaps health
insurers typically are still finding
that there they are primary and
secondary about the same percentage so
basically we are finding a lot more
information and about half the time
they're on the hook to pay and on the
other half of the time there may be
someone else on the hook to pay which
actually kind of follows where we
generally see again across the entire
industry of information so with that I'd
like to hand it over to Christina Welch
from Blue Cross Blue Shield of North
16:03
Carolina to talk about their experience
with CEO be smart and in general how
they run their operation hi everyone hi
I'm going to share with me just one
second here get to our spot
okay just a fun few fun facts about Blue
Cross Blue Shield of North Carolina we
are North Carolina's largest health
16:40
insurer we have a little over 3.9
million members I'm sorry the slide
isn't responding for me there we go
we have 26,000 and network providers
over 4,800 employees and was founded in
1933 okay
17:18
originally what Blue Cross Blue Shield
of North Carolina did as they approached
the benefit coordination before we
implemented Co be smart is we sent out
Co B questionnaires to our members I'm
asking them to let us know of any other
insurance the members could either fill
out the questionnaire or call in to the
call center and give the information
over the phone we also got a co B
information during our group renewals
where the group would advise that their
employees had other insurance they our
membership department also received
17:49
information through the group renewal
process as well they would 4-dan onto
our C our coordination of benefits
benefits investigation team to review an
update if necessary providers were also
a resource for getting in Co B
information is that our members provided
the information to their provider the
provider would submit it to us on claims
and we would be able to investigate it
that way as well providers could also
call in to the call center and say hey
the member had other insurance I'm just
18:21
giving you a heads-up they would give us
the information and we could update that
way as well in 2009 Blue Cross Blue
Shield North Carolina developed us a
coordination of benefits investigation
team specific to just dealing with the
co B updates and handling higher level
investigations where we were having
trouble determining promisee
what worked what we discovered what
worked for for us was the most reliable
was the provider submitting the
information to us also once the co bi
18:58
team was implemented to start doing the
co B investigation specifically we were
able to reduce Co B we were able to
complete Co B resolutions by upwards of
20% in its first year what didn't work
was depending on the member responses we
had a very hard time getting the member
surveys back and often when they did
sought this questionnaires it would be
missing critical information and we
would have to either reach back out to
the member or send another questionnaire
19:28
the group renewals also content would
often contain inaccurate information
that would contain old insurance that no
longer applied or there was no overlap
so we really didn't need the information
and we also have third party automated
enrollment systems there are groups used
that would also often override the
information that we already had set up
so that was not as reliable okay the
19:59
reason why Blue Cross Blue Shield North
Khanna selected Co be smart we
definitely saw the value of a common Co
B registry to help reduce those
administrative cost it also helped
reduce the occurrence of Blue Cross Blue
Shield and Ratana paying out of turn
when the other payer was in fact primary
also looking at it from a proactive
standpoint we were able to use the
registry to get it right the first time
we already have the information or we
could proactively search for it instead
of waiting for that slag from either a
20:29
claim that was submitted with other
insurance or provider calling in and
then having to rework those claims based
on that retroactive information we began
the implementation process at Blue Cross
Blue Shield in North Carolina in
December 2013 we formed the project team
we worked with our internal departments
to determine the best resources for our
business requirements
technical needs we also worked through
20:59
various challenges during the coding and
implementation including we had to
rewrite a lot of the reporting
specifications we implemented the
solution we went live in the first
quarter of 2014 and it's through till
today we're still performing the
validation manually just to make sure
that the information is correct or there
are no conflicts and the primacy
determinations
we are currently laying the groundwork
for automation in 2016
house he'll be smart change the paradigm
21:36
for CLB at Blue Cross Blue Shield of
North Carolina like I mentioned before
we were able to proactively address the
CEO be updates instead of waiting for
the members or the providers to give us
the information
those proactive updates allowed us to
reduce the occurrence of resubmissions
and adjustments of claims we associate a
cost with everything and that allowed us
to reduce those kinds of costs in terms
of the adjustments and resubmissions and
corrected claims that we would receive
in we were also able to reduce claim
22:08
denials due to CEO be said information
came in a claim came in with other
insurance on it we would often have to
pin those claims and wait or deny them
if we couldn't get the information back
now we have fewer investigations claims
are able to go through our system
through the automated system and we
don't have to pin claims an error again
we've been able to notice an uptick of
up to 20% of claims that would have
probably previously tended in our system
they're now able to go ahead and go
through the automated system one of the
22:40
biggest trends that we've noticed other
than obviously members who have spouses
with their own insurance due to the ACA
rule that allowed members to start
covering their children again up to age
26 we have discovered a large subset of
adult children who have their own group
policies and often they often have group
policies through their spouses we've
also been able to reduce the uses of our
health care recovery then
23:11
we're actually able to tag our members
first for investigation and update it
instead of waiting for the subrogation
to come through through the third party
today we have realized over seven
hundred seven thousand dollars in total
savings 305 of that was due to Blue
Cross Blue Shield of North Carolina
being able to proactively access the CEO
be smart information being able to
update those members again not waiting
on the member or the provider to give us
that information
23:47
another 402 was from the providers
resubmitting their claims that we had
previously denied due to knowledge of
other Co B information and this is the
difference between paying primary Blue
Cross Blue Shield North Carolina paying
primary versus paying secondary as we
look toward the future Blue Cross Blue
Shield of North Carolina plans to focus
on automation of our caq H files we want
to be able to just go ahead and run them
24:20
through our system so that our updates
are automatic and a little bit more
timely it will help us reduce the manual
we rework of claims and improve our
workflows and we would like to also work
on streamlining our processes to improve
timeliness to make to kind of work these
files in a more timely manner because
right now they're taking us up to three
to four weeks to manually implement but
we would like to see that reduce down to
seven days or less and now I'm going to
24:54
turn it over to Sean
good afternoon good morning to those of
you in the west coast my name's Sean
Kelly and I'm with Kaiser Permanente
which is based in California
headquarters but has presents nationally
from Hawaii to Washington DC Maryland
area so we're fairly broad although very
dominant in California go go with a
little few facts here about Kaiser
Permanente in general is that as many of
25:32
you probably know Kaiser is a fully
integrated healthcare delivery system
and health plan operating in seven
regions nationally that to here in
California Hawaii the mid-atlantic the
Northwest region around Portland Oregon
did the Georgia region around Atlanta
the Colorado region in Denver and
Colorado Springs are the primary centers
of operation nationally we have about 10
million plus members we just passed the
26:03
10 million mark this year and have had
substantial growth as I'm sure all of
you plants have with with ACA we have
close to hundred and eighty thousand
employees close to eighteen thousand
physicians and 50,000 nurses all within
the overall environment as well as 650
plus here hospitals medical offices and
facilities with with hospitals not you
26:34
know being in the round forty ballpark
in terms of the number of hospitals in
the overall environment Kaiser is a
closed panel plan so I think to give
some context for you all health plans
about 20% ballpark of our total medical
spend is outside medical that varies
quite a bit by region depending on
whether it's a hospital region or not
and then the other 80% of medical spend
is provided by the physicians and nurses
and and other folks here that I have
27:06
listed on this page but still even at 20
percent outside medical that's a
substantial number of claims that we
need to
process and a substantial number of GOP
opportunities that we need to be
attentive to in our in our payment
integrity work so similar to Blue Cross
Blue Shield of North Carolina we had we
had utilized the leads from other get we
27:41
got our other coverage CoV leads from
claims so provider submitted the
information received on claims that we
may have gotten as a secondary payer we
would get information from our recovery
vendors who would source and identify
other coverage although their focus
tends to be more on identifying Medicare
so commercial identifications are not as
frequent and we had mail and telephonic
surveying that we've done various times
28:11
that supplemented that information and
that we experimented with and and
deployed in different regions but the
first bullet here really was our unique
opportunity which was the source of the
coverage data from our own member
interactions at the point of service in
the Kaiser owned facilities and we would
we attempted to leverage that as a first
order approach to getting other coverage
data so what were what were some of the
28:45
the the challenges here I think that are
worth calling out well when of service
inquiries for other coverage were a
great idea but they were performed
rather inconsistently
I mean in the overall organization it
really wasn't in our organizational DNA
for Kaiser front office clerks to be
asking about their other coverage of
their non Kaiser other coverage they it
was it was a process but inconsistently
administered the other thing is that
members were generally confused with
29:17
forms and that caused incorrect
responses and and also we found lack of
full disclosure so often the coverage
that they would provide the coverage
information
they would list with the coverage that
they had just left as opposed to actual
dual coverage the other thing we found
around surveys were the the the low
response rate basically acquitted a
relatively high cost for what I call
acquired OSI I acquired other coverage
29:47
information new data that we didn't have
before and it really impacted it and
made the entire survey process more or
less a break-even proposition it really
didn't have a high value for our
operation and furtherance in surveys
were conducted on an annual basis and
selective we weren't being able to
survey 10 million members and incur that
kind of cost there there was an inherent
time lag required to process all that
data wait for the responses back do vary
30:20
verification and validation and often by
the time you achieve the data that data
was very likely already out of date so
this was problematic and then in our own
operation given the number of regions we
have our transactional systems made it
challenging for us to to manage our
other coverage data consistently across
our entire membership and and regional
operations so let me talk a little bit
30:52
about why we selected seal be smart I
mean fundamentally member data sharing
has always been the holy grail of COP
for folks who are in the co B space they
had always been thinking why couldn't we
do this and so when a CA QH came forward
with this proposal a few years ago it
was really in it and it began to get
traction with the core member plans
within CA QH which represented
substantial market share nationally it
31:22
looked like it looked like a win-win
situation so clearly it was going to be
scalable at an industry level and that
allows us to assess our entire member
roster the entire 10 million lives as
opposed to trying to do
selectively surveying to to only members
or to certain members of a certain age
or likelihood for other coverage to
eliminate the guesswork basically the
31:54
automated file generation as well as the
weekly files the middle allows us to do
this in a in an automated routine non
periodic non intermittent way so once
you've engineered the process of
delivering data and receiving data you
really is sort of set up a machine for
this and it isn't the annual survey that
you gear up for that kind of thing
and I think very importantly the
32:25
solutions non-invasive with members or
groups both of whom we found in our
experience were not forthcoming with
information or reluctant or not wanting
to be in the in the other coverage
providing space so those are those are
things were the key you know factors for
us the implementation approach was very
very successful number one we had senior
32:58
level support which i think was key in
order to get resources to get the
engagement of our IT organization and
others into the overall solution so it
was key to get senior leadership support
and and endorsement sponsorship for this
the actual CA qh sponsored workgroup was
very effective it was a highly
collaborative work group with the member
organizations within CA qh with very
high subject matter expertise and strong
33:30
engagement of all to make this a
successful outcome so a lot of energy
and intelligence went into designing the
membership file specifications and the
return file specifications and so forth
to get to what we thought would be an
industry standard and an industry
scalable solution we had an aggressive
timeline which allowed us not to sagar
or let this
idle we had a very competent technical
team with CAA QH and and the passport
34:00
organization that is the vendor that
that facilitates the utility and all of
this allowed us within Kaiser to use
fewer internal resources from an IT
perspective which was key because this
thing came on very quickly we didn't
have an allocation to to utilize the IT
organization extensively or had budget
and therefore we were able to do this
and relatively efficiently utilizing the
34:29
the external project team and then I
think finally again our success really
dependent on the ability to utilize some
existing warehousing utilities that we
had in flight already and to leverage
those resources that were working on
those data warehousing utilities for
membership and claims and so forth which
meant that independent of the the work
that we did on on laying out the
structure and so forth we were able once
the file spec and so forth were
35:02
determined we were able to put this
thing together and get into production
mode within a relatively short window
like three months
one thing I would call out here is that
we did not engineer a fully automated
data consumption process and we have not
done yet yet we're working on that
similar to I think what I heard from
Blue Cross Blue Shield North Carolina
that's a more complex activity in terms
of getting the data fully integrated and
and consumed into your own system but
35:36
what I would say is it's better to get
going better to get your your data
delivered and get start to get results
and consume them as you can rather than
look and wait for the perfect solution
because we're we're seeing results good
results already from the the process
that we have in place now
so speaking of results I would have to
say the overalls are quite significant
and exceeded expectations the numbers
that Anne showed around 5% of the
36:10
coverage are really quite a high when
you think about the conventional view
that other coverage was in somewhere in
the 1 to 3 percent range prior so there
was a lot of discovery of more other
coverage than before and in fact there
was a high volume and we still see a
high volume of triple coverage which is
not at all intuitive but we see in the
data that there's quite a bit of triple
coverage and in the results this sort of
36:43
this this sort of adhered to what was
sort of the 1090 view before we went in
which some studies showed that you might
have 10 percent of the available
information and in addition maybe 10
percent of the data you do have is
current leaving 90 percent of its tail
so it was a double factor there in terms
of both having high value of having
lower volumes of overall of the coverage
data and the data you have is not
current so this is one of the the key
37:15
things here is that this has shown that
to be true and is solving for that
problem with respect to cost we found
that this whole solution is not over 90
percent reduction in the cost to acquire
the coverage data when I compare it to
the survey process for example in that
process that the cost to acquire a new
other coverage information where the
other cut pair was prime was north of
37:46
two hundred and fifty dollars per
acquired data point now we're looking in
the ten to twenty dollar range to
acquire other cover and other coverage
information is quite a significant
reduction and the yield that we found
from this entire processes is in the
ballpark of a round of 5x pay off to
what are our overall
a costs are I think we've recovered five
38:17
million plus since the inception we've
identified closer to 15 million in Co B
cases that which is sort of an
indication of what the opportunity there
is for us I think a final observation I
would make here is that another thing we
found is that the dollar per case or per
member identification of actual Co B is
quite high I think we're looking at
something in the twenty-five to thirty
thousand dollars per member with Co B
38:48
that's not per member with other
coverage data that means for the actual
cases where there is Co be the actual
dollar return on those cases is in the
twenty-five to thirty thousand dollar
average space so this seems to be an
environment of more of fewer numbers of
hits and higher dollars per hit in the
overall scheme of things independent of
the fact that the overall pool of other
coverage is is quite substantial I think
39:19
with that I'm done and it's now time for
our next presenter
oh I actually have another slide I
apologize so in wrapping up we are as I
mentioned we're focused on processes to
consume these high volumes of data
automatically and populate our claims
transactional systems without using
manual process or manual verification
that's that's coincident with a large
40:01
claim transformational project that we
have underway so that will be happening
for us over the next a year and a half
two years as we as we move through that
claims transformation and integrate this
work with that I think that all the
participants in this collaborative sucia
is solution are working on how to use
this co B data more effectively and
improve the membership data quality that
they that they deliver and that they
have internally and in the key to
40:30
success of this is delivering accurate
and quality data and making sure that
the term dates are correct and accurate
making sure that the health care that
the health benefit status the medical
coverage status of the of the data
submitted is correct and accurate those
are all important aspects that are
continuing to improve in the utility and
we anticipate increased industry
participation and we believe that we
will all benefit from that plans
41:03
providers patients are all going to
benefit as this this utility expands and
more health plans join the existing
group that are already in so now I will
hand it over to the moderator questions
and take it from there thank you very
much for your time
thank you we're now going to have
questions to ask a question via the web
presentation selects it's nap pod
located in the lower left corner of your
41:47
screen then type and send your question
once again to ask the question via the
web presentation select the chat pod
located in the lower left corner of your
screen then type and send your questions
till we're ready to begin okay I think
we'll start within what is an instance
where primacy cannot be established yeah
good question so there's a couple of
reasons why we may not be able to make a
final determination on primacy one is
42:18
just that sometimes we don't get all of
the required data that would help us
actually come to a final determination
so Shawn mentioned the plans work very
close together in terms of trying to
make sure that everybody's submitting
all of the data that will help us make
those determinations but sometimes we
don't get everything we need and when we
don't we may not be able to come to a
final determination but we will again
indicate why we could not the other
reason is that there are instances where
in a good example is in the case of a
42:49
dependent child that they the actual
determination of who's responsible for
that child for insurance would be made
by a court we don't have the information
on any court orders so we would indicate
it does appear to be a dependent child
of a divorced couple and therefore
you'll have to do some more research to
determine who is actually responsible
for the insurance so those are good
examples where others just some subsets
of situations where we just cannot come
to final determination okay thank you
43:21
does Co b-smart work with fhbp plan yes
we do actually have some federal
employee data coming into the system
today so it is capable of identifying
overlaps as well as primacy in that case
and we certainly would welcome that
participation okay and does Blue Cross
Blue Shield of Michigan participate Blue
Cross Blue Shield of Michigan is not
currently participating
they are very aware of this solution and
we're hopeful that they will be able to
43:54
join us in the future all right next
question
can I pas or providers you see Oh be
smart yes
so as we indicated earlier ca qhs
decided to kind of take the existing
path of least resistance in terms of
helping to get this data out to provider
organizations so ultimately that
transaction set is the to 72 71
eligibility request and response so when
44:26
a provider does submit an eligibility
request to the payer that the patient
indicates that they have the health plan
they can submit it and then we are
working with both the health plans and
the clearing houses to be able to make
sure that as much as possible we can get
any information about other coverage
back and also primacy back in the
response to the provider so these are
existing transaction sets that work very
well for indicating that there is other
coverage and we're essentially trying to
44:57
leverage those existing transaction sets
to get that information back to the
providers before they actually submit
the claim ok great
explain whether and how Co b-smart
improves pharmacy Co B and how the
return varies between pharmacy and
medical yeah good question um we have
started out as we develop Co be smart to
first and foremost focus on medical
insurance so we are reporting we are
looking for the overlaps and reporting
45:28
on medical we are actually also
receiving information about pharmacy
dental vision and other types of
coverage so we can provide back
information about the overlap we have
met former formerly very formally
introduced pharmacy yet because there
are some additional fields that we would
like to collect in order to add add
pharmacy and be able to report back on
that information so we don't yet have a
strong indication of kind of the
differences with pharmacy that being
45:58
said as we work with all of their
participating plans we know that
pharmacy is important the special
the costs of drugs and you know continue
to rise and we're going to be definitely
addressing that in the future and we do
expect that it will be a part of CEO be
smart hopefully within the next year or
so okay let's give Ana brake and turn
Shawn regarding the 90 percent reduction
in cost what cost areas are you
referring to I was referring to the cost
of acquiring of the coverage date of the
46:30
processes of surveying and end up
processing surveys and forms and other
manner so not the general administrative
claims costs of performing C of B but
more specifically to the acquired cost
where we don't actively measure the co B
administrative costs independent of
overall claim cost so we don't really
have any data points to share there but
I did have data points with respect to
what I referenced saying that you know
surveying when you actually net it all
47:02
out and looked at what you actually
acquired new in terms of about the
coverage data it was in the hundreds of
dollars per for a new per day per person
acquired that you didn't have before
with versus now in the in the teens okay
and Christina have you experienced
challenges when gob issues arise that
involve a commercial group plan and
either Medicare Medicaid or TRICARE well
47:33
we see that every day so we don't really
it doesn't really throw up a flag we
still have to go back and review on
promise you know review the privacy
determination look at group size um
whether or not the members active or
inactive but we can still use the CEO be
smart information to make those
determinations as well okay and the same
question for you Shawn
have you experienced challenges and gob
issues arise between commercial and
either Medicare Medicaid or TRICARE we
48:06
we have not well I'm trying to
understand this question correct place
let me read it here
commercial and either Medicare medicated
for TRICARE so with Medicare which
Medicare fee-for-service data is not
part of the CFP solution here and it's
in its data you get these through your
your data exchange process with Medicare
or other it's not a lot of controversy
with respect to MSP rules and there's
there's not a challenge there I don't
48:44
think and we in our model Medicaid and
TRICARE are the pairs of last results or
or last in line so we again have not had
a significant issue there with respect
to this utility and govt issues with
them if that's the question hopefully
I've answered the what the what the
questioner is looking for there okay
well I'll ask the attendee to type back
into the chat pod if you'd like further
clarifications so back to an is
49:17
traditional Medicare one of the plans
that will participate yeah actually I
think Shawn actually just answered that
so today traditional fee-for-service
Medicare does not participate and Co be
smart they have their own process for
getting information from health
insurance plans however you know they're
always of course welcome to in the
future and that could happen but we are
not necessarily counting on that to
provide all the benefits of this
particular solution okay
can you explain where you get your
49:47
enrollment information is it from the
carriers your Clearinghouse is service
it is only from the carriers so we do
get this information directly from the
health plans we contract with them to to
provide it and then of course by
participating they also get all of the
information back but all of this is
coming directly from the core systems at
the health plans that have all the
information about their members and the
coverage okay and what seeds are
involved for hospitals to have access to
50:18
the information again as as I mentioned
at the very beginning so CA qhs model is
very much to encourage participation
for providers without charging fees so
this information is available to all
providers that are submitting
eligibility requests for patients that
are coming in to see them and again as
we continue to work with the health
plans to include that information in the
responses to those transaction requests
they'll receive it that way as well as
50:50
we're trying to augment that by working
with clearinghouses that can also access
our database for participating plans
when a request does come in so but there
are no fees for any types of providers
to receive this data okay and can
recovery and cost containment vendors
usio be smart so our model is to really
work directly with the health plans that
do own the data ultimately a lot of our
participating plans do work with
51:20
recovery and cost containment vendors
and they are allowed to to utilize our
information as they work with them for
their own you know to benefit that
particular health plan so we know a lot
of these vendors are very much aware of
Co be smart and even working with some
of the data that we're giving back to
the health plans but first and foremost
we're just out trying to get everyone to
participate because ultimately that's
what will solve this particular problem
is by essentially getting everyone in
the pool so that we can give you know
51:51
the most complete updated information
across the country every single week
okay is there a list available of the
commercial payers that now subscribe to
Co be smart yes I do believe it is on
the CA QH website however if that person
would also like to contact me directly
I'd be happy to provide the list to them
as well okay and an website is on the
slide that's up right now Weber is good
via qh org next question I think we have
time for just a few more are there
52:21
standard Co B processes for retiree
group plans and Medicare who is that
question for
I think probably best for Sean or
Christina so Sean shall we start with
you certainly well I mean if within
there are there established data
exchange programs with Medicare called
some people called the hue or the MIR
management you know mandatory
52:51
information reporting but basically it's
a file exchange with Medicare for
membership that allows the Medicare to
identify members there their fee for
service members who have commercial
coverage and it allows commercial plans
to identify folks with Medicare coverage
it isn't quite as efficient as what we
have with the C aqh you'll be smart
program but it is the main vehicle that
plans utilize with respect to you know
53:23
retiree group plans and group plans and
Medicare the rules with Medicare are
very clear with respect to MSP which is
Medicare secondary payer guidelines
around primacy and the requirements
around the size of the group and is the
person still actively working or not or
is the coverage through a working spouse
or not and other aspects of determining
Medicare primacy so those are all fairly
clear they are not part of this do be
53:55
smart utility at this time what if
Medicare were to join and begin
providing their enrollment roster which
would be ideal then then we would in
Bakke we would incorporate the Medicare
secondary payer Medicare primacy logic
into the program okay Kristina anything
you want to add on to that not not
immediately I feels I feel like Shawn
answered it pretty well for the both of
us okay all right so how much is the
54:25
average cost of Co be smart for managed
care plan yeah I can provide that
specific information back if someone
would like to contact me about it we do
price it on essentially a per member per
year rate so basically it's based on
total membership and that's build on a
monthly basis but
the whole idea here is to keep the cause
very very low for participating plans so
that we can encourage you know broad
participation of course and and again
the CA qh is a non-profit is very much
54:55
focused on not so much making a lot of
money but much more in kind of solving
these problems for the industry so we do
keep our prices low in recognition of
that okay and another attendee wanted to
know if you work with specific clearing
houses like availa to your aquatic I
believe we have spoken to ability in the
past they are not a current Clearing
House that we work with and I'm not
familiar with the other one so I don't
actually know but I'm at this point I
don't believe we do we have started
55:28
working with some of the larger ones
including MD on just in the last six
months or so and those will continue to
get updated as well but if anyone has
specific questions on those I'd be happy
to direct that to the right person at
our organization okay and will Co be
smart with work with a thirsty vendor
like Cobra solutions used by some Anthem
lublin I think as I understand this it's
really asking if we would cover or if we
55:57
will look for coverage that is Cobra and
overlaps with with COBRA coverage and we
do so Cobra as an individual rolls off
of a group plan and picks up Cobra we do
get that indication in all of the
membership information and we would in
fact be able to report back overlaps for
anyone that is on a cobra plan okay and
I think the last question we'll have
time for it does Co be smart only deal
with medical carriers or does it also
have information regarding dental
56:28
carriers yeah good question as I
mentioned earlier we are actually
receiving dental coverage standalone and
and Carvin dental coverage information
from many different of the many
different participating plans so we can
indicate overlaps on those we are
looking at adding dental kind of down
the road as I mentioned along with
pharmacy meaning actively reporting out
in charge
for those overlaps along with that
though we do know we would need to get
57:00
some of the large standalone dental
carriers in the network and they're not
currently part of it today okay
so with that I'm afraid we're out of
time for today's webinar so I invite all
attendees to email any questions that
you did not get answered to and her
email address is up on the screen now
ABR is k @ c AQ h org i'd like to thank
and christina and shawn for their
discussion of co be smart and i'd like
57:31
to thank the audience for your
participation as well have a great day
this concludes today's webinar thank you
for attending
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