A high tech/high touch approach controls costs while enhancing health coverage

June 03, 2021
Matthew Hemberger
Program Manager Enhanced Coordination of Benefits

In Massachusetts, through a strategic, high tech/high touch approach to member outreach, claims review and cost control, patients and those who care for them are gaining peace of mind, and MassHealth, the state’s Medicaid program, is realizing millions in total savings.

One way that MassHealth helps to controls costs is through Enhanced Coordination of Benefits (ECOB) programs designed to identify other payers who may be responsible for providing coverage of health care services. This ensures that, when appropriate, Medicaid beneficiaries with complex and high cost services have access to the full scope of health insurance benefits available to them, while MassHealth remains the payer of last resort.

Enhanced Coordination of Benefits: comprehensive and collaborative

Commonwealth Medicine’s ECOB program takes a comprehensive and collaborative approach to controlling costs. It uses a combination of high tech data review and high touch engagement with providers, plan administrators, beneficiaries, and their families.

Our embedded ECOB insurance coordinators work alongside hospital clinical and financial staff to identify and optimize third-party insurance and resolve coverage issues. Our data mining and medical and pharmacy claims review processes identify individuals with medical complexities and high utilization of services —including those diagnosed with cancer, cardiovascular disease and trauma, or requiring neonatal intensive care or organ and stem cell transplants—and maximize third-party payers for these high-cost cases.

We meet with referred Medicaid beneficiaries and family members to offer easy-to-understand explanations about how their private and public health insurance benefits coordinate. We then perform a variety of Medicaid Third Party Liability (TPL) system audit and maintenance activities to ensure Medicaid remains the payer of last resort when processing claims for applicable services.

We also work with hospital staff, attending clinical and financial rounds, assisting care coordination teams to resolve coverage issues, and reviewing hospital patient insurance information to initiate Medicaid system update requests when needed. In addition, we provide ongoing education to hospital staff on TPL programs as well as quarterly reports to hospital administrators.

Spurring savings – and significant value

This combination of focused efforts – a blend of high tech data review with high touch engagement to maximize third-party payment for costly cases – saw the MassHealth ECOB program yield $60 million in total savings for FY20.

A customized ECOB program can deliver significant value to Medicaid programs by controlling costs while offering appropriate coverage to beneficiaries facing complex procedures or recoveries.

The past few years have demonstrated the success of a proactive approach to cost saving through data analysis, leading to significant savings while assisting vulnerable individuals in accessing the full scope of benefits available.

And now, with the recent passage of the American Rescue Plan Act, which offers opportunities for expanded COBRA access for beneficiaries and provides an additional temporary fiscal incentive to encourage more states to adopt Medicaid expansion, the value resulting from targeted management of Medicaid populations is within reach for others.

To learn more about Commonwealth Medicine’s ECOB Program, contact Matthew Hemberger, Senior Program Manager.