1. Introduction to COB Smart®
AAHHSA Conference
November 16, 2016

2. Contents About CAQH COB Challenges COB Smart Solution Overview
Health Plan Adoption and Results
Provider Access
Summary

3. About CAQH
CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients and health plans.
Perhaps add a sub-bullet for provider directory under ProView and also for PSV Solution. Marketing team to think about re-organizing this slide

4. CAQH Initiatives
Replace with updated logo slide when available.

5. Industry Collaboration as a CAQH Strategy
CAQH seeks to collaborate and build consensus among involved stakeholders for lasting, effective change by:
Aligning stakeholder goals.
Creating focused direction.
Health plans can:
Act as catalysts for change.
Reduce complexities of inefficient business processes.
Implement consistent approaches to non-proprietary processes by participating in shared, industry-wide initiatives.
Healthcare Providers can:
Promote and request consistent approaches across their vendors.
Participate in initiatives that reduce their administrative burden and costs.

6. CAQH Members

7. The Coordination of Benefits Challenge
Related Inefficiencies
Patient paperwork.
COB denials and resubmissions.
Unpaid or delayed payments.
Overpayment recoveries.
Appeals and grievances.
Financial impact on practice operations.
Does my patient have multiple coverage?
Which insurer is primary?
Better bubble 7

8. Health Plan Pain Points
Summary of Health Plan COB Pain Points
Members often unresponsive to inquiries or do not have accurate/complete information.
Health plan difficulty identifying the secondary health plan based on the claim.
Lack of transparency into other health plan’s responsibilities and payments.
Lack of standardization between transactions, leading to high manual touch for resolution.
Provider claims do not provide consistent information needed for accurate adjudication.
Method for identifying primary and secondary ownership varies among health plans.
Inaccurate and missing data often keeps claims pending, leading to high manual processing.
Members frequently change health plans leading to inaccurate eligibility data and COB identification.
Inaccurate data provided by other health plan causes under- or over- payments.
Poor Cross Health Plan Information
Lack of Uniform Process for COB
Delete 3rd column, see slide 10
Data
Inaccuracy 8 8 8

9. Provider Pain Points
Administrative burden collecting coverage information at point of service (e.g., different forms, formats, rules).
Patients provide unreliable coverage information.
Care givers may not know relevant coverage information.
Lack of visibility into a patient’s cross-health plan coverage and benefits.
Lack of visibility into progress of submitted COB invoice.
Low transparency of processes for reimbursements, appeals, and adjustment.
Existing rules, such as statutes of limitations, do not account for COB complexity.
Claims rejected due to different provider interpretations of primary and secondary health plan hierarchy.
Multiple COB claim filing formats leads to manual massaging or technology complexity.
Providers spend substantial time manually processing bills.
Providers experience increased processing time and significant delays in collection.
More staff required to follow-up on denials and appeals.
Poor Patient Information
Fragmented Lifecycle Transparency
Lack of Uniform Process for COB
Manual Processing 9 9 9

10. Current “Reactive” COB Strategy
Plans forced into a reactive strategy in determining and investigating COB.
Resource intensive process with frequent unfavorable outcomes.
Provider Billing / Claim Receipt
Routing
Claim Adjudication
EOB/Claim Payment
Patient Access and Eligibility
Appeals & Adjustments
Missing or inaccurate patient information.
Manual downstream.
Lack of uniform use of billing codes, complicating COB reviews.
Extra paperwork from denials and resubmission.
Incorrect bill submission (e.g., to the wrong health plan).
Results in repeat bills.
Ad-hoc patient data requests.
Confusion over primary health plan COB payment.
Results in significant manual turn around time.
Confusion over health plan payment (i.e., ambiguous EOB).
Results in lengthy and manual secondary COB bill submissions.
Manual work associated with non- standardized appeal processes. 10

11. COB Touchpoints Across the Enterprise
Use data in claims processing workflows
Load data into primary membership systems
Disclose data in plan created HIPAA 271 responses to external inquiries
Empower providers with robust COB data for their patients
Use data in claims investigations and recovery
Karen - make graphic easier to read. 11

12. Estimated Costs of COB Administrative Inefficiencies = $800M
Estimated Annual Costs for COB Inefficiencies
(in $M)
Highlights
Figures based on interviews, internal data analysis and industry research.
Providers are burdened with ~60% of the extra costs, of which $430M are billing related (primary and secondary billing processes).
FTE costs represent $500M (60%) of extra costs.
IT and vendor spend represent the remaining $340M (40%) of extra costs.
$<1
$350
Health Plan
Provider
$490
$230
$<1
$70
$<1
$<1
$40
Patient Access & Eligibility
Provider
Billing / Claim
Receipt
Routing
Claim
Adjudication
EOB / Claim Payment1
Appeal and Adjustments
Total
1) Claim Payment includes EOB review (for secondary billing) and claim payment assessment.
Source: Booz & Company Analysis; Stakeholder Data Requests. 12

13. Requirements for Efficient, Industry-Wide COB
Easily determine primary and secondary payers for health claims through system integration and automation
Inform providers of overlapping coverage and correct order of benefits before care is delivered 13

14. COB Smart: Meeting the COB Challenge
COB Smart is a collaborative, secure solution developed in partnership with health plans. It automates the COB process to:
“Get it right the first time.”
Shares accurate and complete COB information with appropriate providers and health plans.
Built-in primacy engine determines correct order of benefits.
Identifies individuals with overlapping coverage across multiple health plans. 1 2 3 14

15. High-Level Solution Overview1
Participating health plans submit a thin layer of enrollment data weekly 2
COB Smart determines overlapping coverage including primacy.
Health Plans
CAQH COB Solution
Providers
Health Plan A
Physicians
Member Matching
COB Registry
Facilities
Primacy
Rules 4
COB data is also available to providers via 271 responses
Health Plan B 3
Participating health plans receive a weekly COB report 15

16. High-Level Primacy Logic
Subject to COB?
Medicaid Record?
Medicare Record?
No Contractual Provisions?
Subscriber or Dependent?
Active Employment or Retirement?
COBRA or Coverage Continuation?
Length of Plan Coverage? 16

17. High-Level Member Matching Logic
Full Name
Date of Birth ?
Suffix (e.g.,Jr.)
Gender
SS#
Address 17

18. Participating Health Plans Include:* * *
* Implementation in Q1 2016

19. A National Database is Crucial to Identifying COB
COB Smart includes both resident and contract state information:
Resident State – Location of member.
Contract State – Location of member’s policy used to determine primacy rules (e.g., employer location for employer-sponsored coverage).
One-third of the members included in COB Smart have resident states different from their contract states.
Looking only in-state for COB is insufficient. A national perspective is required to find COB. 25

20. COB Smart: First Nationwide Commercial COB Database26

21. Results On average, COB Smart is finding overlapping coverage for:
5.1% of the overall medical membership.
5.5% of commercial group [ranging from 3% to 8.5%].
4.3% of individual [ranging from 1% to 6.5%].
4.5% of Medicaid MCO [ranging from 4% to 18%].
2.3% of Medicare Advantage [ranging from 1.4% to 4.5%]
12% of total matches are internal to a health plan.
On average, participating health plans find that primary and secondary coverage is evenly split (50/50) for newly found overlaps. 27

22. Examples: Newly Identified COB and Confirmed Data Accuracy
Plan identified 9,158 overpaid claims = $6M
*Internal payer validation by contacting other plans 28

23. Examples: Newly Identified COB and Confirmed Data Accuracy
Results from Two Newly Participating Regional Heath Plans 29

24. Health plans have been able to increase the rate of COB detection by 40%
Health plans report that legacy methods have been able to identify COB in 5% of their respective membership.
More than 80% of this, on average, is derived from Medicare reporting.
Commercial COB typically represents less than 20% of total identified COB cases. Importantly, this data is often highly inaccurate due to quality challenges associated with member surveys and other legacy identification methods.
COB Smart enables a 40% increase in the overall rate of COB detection.
These cases represent net new COB and were previously undetected – primarily due to the nature and complexity of identifying commercial overlaps.
Data quality is substantially higher due to automated weekly updates and “direct from source” information.
Additional undetermined COB cases that can be identified yield potential cost of care savings.
Knowledge of cases in which the health plan pays primary can improve eligibility responses and claims submission accuracy, thereby reducing member and provider abrasion.
40% increase
*CAQH participating health plan experience, large national health plan over two years with COB Smart.

25. Creating a Better COB Experience for All Stakeholders
Members
Fewer member surveys.
Fewer delayed or rejected claims.
Fewer claim-status inquiries.
Providers
Reduced staff time following up on claims.
Improved cash flow.
Plans
Reduced “pay and chase.”
Increased recovery dollars.
Reduced claim rework.
More accurate determination of primary and secondary payer status.
Check webinar deck 31

26. Supplying Accurate COB Information to Providers
Provider sends a 270 eligibility query to health plans, which in turn send a corresponding 271 eligibility response.
Participating plans can access accurate overlapping coverage information from COB Smart to enrich the 271 response sent to providers or displayed on a portal.
Participating clearinghouses can also access COB Smart information to include in the 271 response.
ILLUSTRATIVE
CAQH Coordination of Benefits Information
Information:
Other or Additional Payer
Coordination of Benefits Date:
01/01/2010
Other Payer Name:
Health Plan B
Member ID Number:
XX XXXX
Detailed COB information via 271 EB*R segment (additional data elements available) 32

27. Opportunity to Improve COB Engagement with Providers
Provider receives insurance information from member and asks clearinghouse to confirm eligibility.
Practitioners
Facilities
Providers
Member Matching
Primacy
Rules
COB Smart®
Participating health plans submit a thin layer of enrollment data weekly. 1
Participating health plans receive a weekly COB report to guide payment decisions. 2
Clearinghouse submits an inquiry for a COB Smart participating plan to the payer and to COB Smart, and receives responses with coverage and primacy information on other participating plans.
Health Plan A
Health Plan B
COB Registry
Clearinghouse
Clearinghouse reports combined member eligibility with COB and primacy information to provider via enriched 271 response. 4 5 3
To be updated. 39

28. Reporting COB Data on the 271 Response
Accurate COB data at the time of service enables providers to:
Submit a claim to the correct health plan the first time.
Avoid errors, rework, resubmission and withdrawn payment.
Improve practice operations, cash flow and reduce administrative costs.
Increase patient satisfaction with provider claims and billing process.
Ensures providers receive COB and primacy information regardless of the communication channel used.
Several participating plans are currently reporting COB data on eligibility responses to providers.
CAQH resources are available to work with health plan EDI teams.
The CAQH Trading Partner program enables clearinghouses, RCM and PMS vendors to access COB information for inclusion in 271 responses as they process provider 270 eligibility inquiries. 33

29. Summary: Get It Right The First Time With COB Smart
Collaborative, secure solution developed in partnership with health plans to automate the COB process and “get it right the first time.”
Improve accuracy, timeliness and secure availability of coverage status information when processing claims.
Improve provider network and member satisfaction.
Reduce staff burden and save money. 35