The Centers for Medicare and Medicaid Services (CMS) requires MA and PDP health plans to update systems timely and accurately. Consolidating and analyzing COB & MSP data collections while maximizing recovery options and complying with CMS regulations is a challenging task. Incorrect data sets can easily contribute to non-compliance and lead to inaccurate claims payments, costing organizations hundreds of thousands of dollars every year.
About MSP and COB
Medicare Secondary Payer (MSP), the process within medical claims adjudication, determines if members have other health insurance coverage. CMS’ MSP data is a monthly, cumulative file.
Coordination of Benefits (COB), the process within pharmacy claims, determines if members have additional prescription drug coverage. COB data is a daily file with annual full-replacement files.
CMS reviews these processes in the One-Third Financial Audit.
Without the support of a software tool, consuming and processing CMS’ MSP & COB data is a complex, labor-intensive process.
CODY’s Membership Suite™™ Reconciliation System bridges the gap between CMS’ requirements and health plans’ administration of MSP & COB processes.
SyncRecon™ is a data-driven system that ingests your plan membership and CMS-generated files to identify actionable MSP & COB cases. The system creates transactional records for appropriate validation and dispositioning while producing valuable reporting for downstream processes.
The following SyncRecon™ modules are essential to MSP & COB processing:
Other Health Insurance (OHI): Our OHI solution combines the MSP & COB modules to optimize data management and produce clean validation records.
- MSP Module
Uses CMS’ Part C MSP file to identify possible records for capitation recovery and validation. Removes duplicates, efficiently groups records, tracks ECRS submissions and reconciles primacy flags in a claims payment system. Pairs with the COB module to increase efficiency and identify overlaps in both CMS files.
- COB Module
Uses CMS’ Part D COB file and customizable business rules to identify new enrollees and annual records within the CMS regulatory timeframe. Supports updates to downstream claim systems. Mitigates risk, increases accuracy, and decreases admin costs. Identifies tracks and maintains members’ 12-month COB history to minimize unnecessary outreach and reduce bothersome member correspondence. Supports maintenance of accurate TrOOP data. Satisfies requirements within the One-third Financial Audit.
SyncRecon™ Maximizes Recovery and Supports Health Plan Operations
Whether our SyncRecon™ system is used as a stand-alone solution or combined with BPaaS, our clients have realized a substantial net gain in recoveries during a three-year period. Our system provides quarterly financial reporting to keep clients abreast of MSP recovery activities.
By implementing CODY’s SyncRecon™ & BPaaS solution, a leading not-for-profit healthcare system in the Southwest with an average membership of 30,800 realized an overall ROI of 379%.
In addition, clients become more proficient in administering these processes to ensure ongoing compliance with CMS requirements.
SyncRecon™ maintains a detailed audit trail of MSP & COB records with associated updates and member correspondence which is crucial for CMS audits. Since switching to SyncRecon™, all clients using Membership Suite™™ tools report no findings or observations during their One-Third Financial Audits.
- Send and receive MSP & COB updates to COB Contractor (Electronic Correspondence Referral System (ECRS) manually or via the SyncRecon™ ECRS batch process
- Maintain MSP & COB information at a member level, including CMS data records
- Weekly and monthly reporting provided, including quarterly financial reports to determine recovery amounts from CMS
- Weekly OHI data for proper disposition in PBM and claim systems
- Provide Third Party Liability (TPL) data sets to assist in obtaining maximum recovery dollars when performing subrogation activities
- Streamline processing to gain efficiencies and increase ECRS acceptance rates
When & Why Business Process as a Service (BPaaS) Makes Sense
As CMS’ transactional processing becomes more complex and administrative costs continue to rise, health plans must discover new ways to increase efficiency and maximize outcomes.
Staying current and compliant with policy changes and up-to-date with membership data and reconciliation are challenging tasks for many—if not all—health plans.
If your plan is understaffed, budget-conscious, and/or growing, choosing BPaaS support can make all the difference to your organization, members, and bottom line.
Regardless of your membership numbers, CODY® offers sliding-scale staffing solutions to manage COB & MSP processing. Our BPaaS model creates plan-specific operational processes to provide end-to-end support to increase revenue, align with CMS regulations, and optimize member and provider experience. CODY’s BPaaS team of tenured subject matter experts has decades of Medicare Advantage operations experience.
We’re Here to Help
CODY® bridges the gap between health plans serving the Medicare market and the government agencies where they contract. We have led the industry for decades—and we have the tools and resources to serve you. Please contact us today for a consultation.
About CODY: CODY® works with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Membership Suite™™, our proprietary suites of software, are designed specifically for health plans. www.codyconsulting.com