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What Makes a Coordination of Benefits Program Best in Class?

The hands of four unrecognizable people are shown fitting puzzle pieces together on the floor, representing the various components that must work seamlessly together to create a robust and effective coordination of benefits program.

Purpose-driven innovation, industry expertise and a relentless pursuit of excellence are the raw ingredients that fuel any “best in class” program. These same attributes drive the Gainwell Technologies team to continually revolutionize coordination of benefits (COB) for Medicaid programs.

Nearly 40 years ago, our business leaders first collaborated with both state and federal governments to pioneer the Medicaid Third Party Liability (TPL) program. From those early beginnings, the industry has continued to evolve and TPL programs now preserve billions of taxpayer dollars in annual Medicaid savings. By remaining the payer of last resort, Medicaid is best positioned to deliver its mission of providing safety net healthcare services to vulnerable children and adults. As a partner on that journey, Gainwell has consistently provided our Medicaid-sponsored clients with the necessary expertise and ingenuity to help meet their goals.

I am enthusiastic about the leadership position that Gainwell has earned since we implemented the country’s first outsourced TPL program in 1985. COB is complex, and as the healthcare industry has evolved, the need for business partners that provide legislative support, technology enablement and healthcare data insight is critical to attain program success. Our Gainwell team continually meets the challenge to identify opportunities that make our clients’ unique COB/TPL programs operate with agility, accuracy and speed. Our ability to execute these initiatives means that Medicaid dollars are optimized.

Big Data + Advanced Analytics = Impressive Results

Identifying other coverage available to Medicaid members — whether from commercial payers, TRICARE or Medicare — is the foundation of any effective COB program. But basic demographic matching has become increasingly challenging because of HIPAA regulations limiting the use of SSNs, proprietary carrier membership formats and the proliferation of benefits managers. Recognizing the need for more advanced capabilities to identify Medicaid members with other coverage, Gainwell developed a Big Data-driven approach to coverage identification.

First, we invested in developing an enterprise Master Member Index that aggregates longitudinal data on over 300 million unique individuals, including eligibility, claim and demographic attributes. These records are continually refreshed and augmented with national demographic and other data sources to ensure optimal accuracy. Our data augmentation, cleansing and enhancements of the Master Member Index enables us to increase TPL identification up to 20% over standard industry matching results. 

At the same time, our member-centric approach to TPL identification enables us to leverage artificial intelligence in order to identify gaps in coverage that we encounter. By marrying our team of data scientists with the rich eligibility and demographic data assets that we maintain (including the Master Member Index), Gainwell is able to predict coverages held by a member, which we then confirm with carriers directly. As a result, we can rapidly create and deliver a comprehensive member insurance profile to our clients so that they minimize their payment exposure across all potential claim types.

Predicting Claim Recovery Outcomes with Machine Learning

Owing to its size, Medicaid often covers a broad base of services, expansive provider networks and generous formularies. Yet when pursuing recovery on TPL claims, liable third parties may reject claims for any of these reasons.

Gainwell’s experience processing over $80 billion in TPL claims monthly has yielded a wealth of historical data that we use to assess a Medicaid claim’s probability of payment from a liable commercial insurer. Harnessing technological power and machine learning, we incorporate these past billing outcomes into our algorithms in order to score each outgoing claim we bill on our client’s behalf. Through this scoring, we predict a claim’s likelihood of being paid, the expected payment amount and even the carrier’s anticipated processing time.

Gainwell’s ability to accurately score each claim helps us to prioritize our subsequent recovery optimization efforts and focus on claims with the highest likelihood of payment. At the same time, we provide insights to our customers on how best to configure their claims adjudication systems to optimize both pre-payment and post-payment cost containment efforts.

COB: Work Smarter

For every administrator of a Medicaid program, enforcing TPL is a requirement. For any program that wants to operate with greater efficiency and effectiveness, Gainwell’s best-in-class capabilities are a must-have.

If you’d like to learn how your organization can benefit from Gainwell innovations resulting from our relentless pursuit of advancing COB/TPL outcomes, please contact us.

About the Author

Ron Singh is the senior vice president for Coordination of Benefits (COB) Product and Delivery. He is responsible for developing and executing the company’s COB product roadmap and delivering cost containment solutions across the pre-payment, post-payment, case management and advisory services product lines.