COB and why you need to check it regularly

Insurance coverage information is often confusing. Some of your patients may have coverage with up to 4 insurances or benefit plans. For example, Mary may have an active plan with both Medicare and Medicaid, Aetna, and Empire Blue Cross Blue Shield. At the same time, Mark may be an active FidelisCare subscriber, who also brings his Elderplan and Medicaid insurance ID cards to an appointment. As a result, you may find yourself bewildered and do not know which insurance to submit a claim for your services to. To put it simple, you are not sure which insurance is supposed to pay for your services. No need to worry – every healthcare provider has encountered such cases at some point.

Coordination of benefits (COB) is an individual rule that determines which payer is primary and which one is secondary. By “primary” we mean a plan that pays for your service itself. While a “secondary” payer is the one covering all the remaining expenses after a primary plan payment. There may also be a “tertiary” payer – insurance that covers the remaining balance after both a primary and a secondary payer have made their contribution.

Let us explore the case study mentioned above to see what all this really means. Mary has Aetna as her primary payer. At the same time, you have found out that her Empire Blue Cross Blue Shield coverage is secondary. It means that her Medicaid & Medicare coverage is tertiary.

But that does not answer the question of where to submit your claims, does it?

In this particular case, you should first submit your claim to Aetna, since it is a primary payer. Then, if there is any deductible, coinsurance, or an out-of-pocket expense – Mary’s secondary claim would need to be submitted to Empire.

How to properly determine a patient’s COB

Coordination of benefits must be discovered upon an eligibility verification process. Whether you check your patient’s eligibility online or via phone call to customer service, there is always an option to inquire if a certain payer is primary during the process.

Can there be a discrepancy between the payers?

Yes, unfortunately, insurances and various benefit plans often do not have accurate information in their records. For example, Mary’s Aetna coverage may be showing up as “secondary” on Aetna’s provider portal, while it is in fact secondary. As a result, Mary would have two secondary payers – Aetna and Empire Blue Cross Blue Shield, and no primary payer that would pay for your procedures. Such cases are always “curable” – Mary would simply need to contact Aetna herself and ask them to update the information.

Proper COB verification is critical for your claims to be paid promptly. WCH Eligibility tool is a handy solution that can save you from potential claim denials. Our software allows you to check the validity of a patient’s insurance coverage and its coordination of benefits.