Coordination of Benefits Registry for Health Plan Payment Apportionment
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Solution Overview
Problem
The existing systems and methods for coordinating benefits among multiple health plans often result in inefficiencies, such as incorrect or incomplete health plan information being provided to healthcare service providers, leading to improper payment requests and increased costs, due to unclear primary and secondary payment responsibilities among health plans.
Innovation Solution
A system utilizing a Coordination of Benefits (COB) computer that obtains and correlates health plan information to generate a COB registry, which includes primacy information to identify primary, secondary, and other payment responsibilities, facilitating accurate payment apportionment and communication between health plans and service providers through inquiry/response messaging.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Adaptability or versatility
If health plan information is obtained from multiple health plans independently, then each health plan can maintain its own coverage information, but the coordination of benefits and payment apportionment becomes complex and error-prone
Solution Approach 1:
The patent introduces a Coordination of Benefits (COB) registry as an intermediary system that receives coverage information from multiple health plans and provides coordinated payment information to healthcare service providers. The COB registry acts as a mediator that consolidates data from multiple sources (improving adaptability) while centralizing the coordination logic (reducing complexity). This intermediary structure allows health plans to maintain their independent coverage information while the registry handles the complex payment apportionment rules.
2Quantity of substance
If healthcare service providers bill multiple health plans, then complete payment can be obtained for healthcare services, but incorrect or incomplete health plan information leads to improper payment requests and increased costs
Solution Approach 1:
The patent implements preliminary action by having the COB registry determine and communicate payment responsibility information to healthcare service providers before billing occurs. The system pre-establishes which health plan is primary and which is secondary for each member, and provides this information to providers in advance. This allows providers to bill the correct plans from the outset, preventing incorrect payment requests and reducing the need for subsequent corrections or appeals.
Solution Approach 2:
The system incorporates feedback mechanisms where the COB registry receives updates from health plans about coverage changes and member information, processes this information through coordination rules, and provides updated payment responsibility information back to healthcare service providers. This continuous feedback loop ensures that providers always have access to current and accurate billing information, improving measurement precision while maintaining complete payment coverage.
3Ease of operation
If one health plan is unaware of another health plan's coverage, then billing can be simplified to a single plan, but correct apportionment of payment among primary and secondary health plans becomes problematic
Solution Approach 1:
The patent merges information from multiple health plans into a single COB registry that consolidates coverage data from both the primary and secondary health plans. Instead of requiring providers to separately query each plan or rely on incomplete information from one plan, the registry combines all relevant coverage information and applies coordination of benefits rules to determine proper payment apportionment. This merging maintains ease of operation for providers while ensuring reliable, accurate payment distribution.
Data Source
AI summary
The disclosure relates to systems and methods of facilitating the coordination of benefits for a plurality of health plans that individually have at least some responsibility to pay for healthcare services received by members covered by more than one health plan. The coordination of benefits may be facilitated before payments are made, streamlining the payment process. The system may correlate health plan information received from various health plans and determine that a particular member is covered by more than one health plan based on the correlated health plan information. The system may generate, update, and provide a COB registry that includes coverage information related to other health plans that cover the particular member. The COB registry may include primacy information used to identify health plans having primary, secondary, and/or other responsibility to pay for a given healthcare service for a member covered by the identified health plans.