Proactive COB Matching System for Payer Data Normalization
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Solution Overview
Problem
Current coordination of benefits (COB) methods in healthcare lead to administrative challenges, including wasted costs, claim delays, and increased workloads for insurers due to unclear primary and secondary payer responsibilities when individuals are covered by multiple insurance plans.
Innovation Solution
A proactive system that maintains a database of membership data, normalizes payer data, and uses matching engines to determine primary and secondary payers, providing real-time output to insurance providers, thus eliminating administrative hassles and costs.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If healthcare providers manually determine primary and secondary payers using traditional COB methods, then claim processing can proceed, but administrative costs and workloads increase significantly
Solution Approach 1:
The system performs preliminary actions by proactively identifying COB instances and determining primary/secondary payer relationships before claims are submitted. Membership data is normalized and matched in advance, creating a ready-to-use determination that eliminates the need for manual administrative work during claim processing.
Solution Approach 2:
The patent introduces an intermediary COB determination system that acts as a mediator between multiple insurance payers and healthcare providers. This intermediary automatically resolves payer relationships by matching membership data against known COB patterns, reducing the administrative burden on providers and eliminating the need for manual coordination between payers.
2Reliability
If claims are submitted to multiple payers simultaneously, then the correct payer may be identified, but claim overpayment risks and administrative rework increase
Solution Approach 1:
The system performs preliminary COB determination and payer identification before claims are submitted to multiple payers. By proactively matching membership data and determining the correct primary and secondary payer relationships in advance, the system prevents claim overpayments and eliminates the need for administrative rework when payers dispute payment responsibility.
3Ease of operation
If traditional COB methods are used without automated matching, then implementation is simpler, but claim delays and service workarounds occur
Solution Approach 1:
The system performs preliminary normalization and matching of membership data in advance, creating a ready-to-use COB determination that can be quickly applied during claim processing. This preliminary action eliminates time-consuming manual lookups and service workarounds while maintaining relative operational simplicity through automated rule-based matching.
Data Source
AI summary
Proactive resolution of coordination of benefits (COB) issues is provided. Payer data is received as membership files from a plurality of payers, the payer data including eligibility and member demographic data. Upon detection of new or modified information, a normalizing engine may be utilized to normalize name information, address information, and social security number information into a format for comparing with other stored payer data according to various rules. A matching engine may be utilized to compare the normalized payer data against other insurance provider data to determine COB instances by discovering matches or partial-matches of member information. A set of rules may be applied to determine a primary versus a secondary payer. An output file, which may comprise matches and COB determinations, raw data, and a web interface for accessing archived reports and files and to generate individual member searches, may be provided to one or more payers.