How Coordination of Benefits Impacts Billing for ABA Services
If you're an ABA (Applied Behavior Analysis) provider or biller, you know that billing insurance is essential to ensuring families have access to care. It’s also a primary source of revenue for most ABA organizations. But navigating the complex world of insurance and billing can be a daunting task. One often confusing aspect of billing for ABA services is understanding coordination of benefits (COB). You may already be asking questions like: Why did I receive denials for coordination of benefits? How do I know which insurance policy is primary? How can I prevent COB issues in the future?
In this article, we'll examine how multiple insurance policies coordinate benefits and why it’s important for both ABA organizations and the families they serve. We'll also look at ways to reduce unnecessary coordination of benefit (COB) denials and discuss some workflows that optimize your ABA billing and help your clients maximize their insurance benefits.
What is “Coordination of Benefits”?
When a client is covered by two (in rare scenarios three) health plans, the insurance companies need to determine who will be processing claims as primary, and who will be processing the claims as secondary, by following a set of rules called “coordination of benefits”.
Why coordination of Benefits is Important for ABA Billing
The process of coordinating benefits can help with the following:
Maximize the clients health insurance coverage
Identify which plan is primary and which is secondary
Prevent duplicate payments between insurance companies
Prevent denials which increases reimbursement, and reduces revenue delays
Understanding Coordination of Benefits
Navigating coordination of benefits can be a bit of a slippery slope. Benefit coordination varies based on the circumstances of each insurance policy. However, there are a set of rules established that can help you better determine how plans work together.
Client covered through an employer: When the client is covered through an employer sponsored plan, that plan will always be primary over a plan where the child is the dependent.
The “birthday rule”: If both (or neither) plans are under an employer, the primary plan is determined by which parent/guardian’s birthday falls earliest in the year. It’s important to note that the “birthday rule” applies to the birthdate that falls earliest in the year, not the year itself.
Example: Mom’s birthday is May 10th, 1987. Dad’s birthday is November 5th, 1986. Mom’s policy would be considered the primary plan because May is earlier in the year than November.
FAQ - What if both subscribers share the same birthday? In this instance, the insurance plan that has been in force the longest would be primary.
Client is covered by Medicaid: If the child is covered by a Medicaid plan (includes Medicaid Managed Care Plans) and is also covered by a guardian’s commercial insurance, Medicaid will always be considered the payer of last resort.
Note: Although Medicaid will always be secondary (or even tertiary), it is imperative that families keep coordination of benefit information updated with both the commercial and state plans.
THE ROLE OF THE FAMILY In OPTIMIZING COORDINATION OF BENEFITS WORKFLOWS
To maximize potential insurance coverage and reimbursement, and to eliminate the risk of denials and unnecessary client costs, it is imperative that families understand their role in coordinating benefits. Policyholders must not only update coordination of benefit information annually with each insurance plan, but are obligated to disclose ALL policy information.
Q: If a client only has one insurance plan, are you still required to update coordination of benefits with the payer?
A: Yes! If the coordination of benefit questionnaire does not get submitted annually by the subscriber, the insurance payer may refuse to pay claims until the information is received.
We recommend families update their insurance payers any time they have policy changes. These changes could include a plan terming, adding a new plan, or even coverage changing through a different provider. At Keystone, we typically remind families of this when we perform our Financial Advocacy Call.
THE IMPACT OF COORDINATION OF BENEFIT DENIALS
If coordination of benefits is not clearly communicated with all insurance payers and the ABA service provider, you will either be overpaid or underpaid. Both situations can negatively impact your revenue.
In the first scenario, you may receive duplicate payments for the same claim. Although the idea of getting paid twice might not seem so bad - ultimately, it can create situations where you don’t get reimbursed at all. Overpayments can create additional work for billing staff, requiring recoupments or refunds to be generated. Additionally, if the secondary plan pays as primary in error, you may not even realize there is an issue until the plan requests their money back in the future. If this mistake isn’t caught within the primary plan’s timely filing period, you may be ineligible to file the claim with the primary plan, resulting in a provider write-off or an unexpected out of pocket cost for the family.
On the other hand, you may begin to see denials from insurance stating the member has other coverage. Since ABA clients are often seen frequently, this can create a large number of denials in a short amount of time, delaying revenue significantly, and increasing billing overhead costs.
Perhaps the most unfortunate COB scenarios occur when a family doesn’t inform you of insurance changes or policies. Regardless of whether you had the correct information provided to you, once insurance payers identify coordination of benefit errors, they will take steps to recover payments paid incorrectly. This could potentially mean months of reworked claims, recoups, retro authorizations; you name it. If these denials or recoups happen outside of timely filing or prior authorization deadlines, you may end up in a situation where you are unable to recover payment for services.
GET AHEAD OF COORDINATION OF BENEFIT ISSUES
One of the best ways to prevent denials or overpayments due to coordination of benefits is to inform and communicate. Having an open line of communication between the family, your organization, and your billing team, is extremely important. We suggest taking the following steps to ensure your organization and the families you serve have the best information possible.
Inform families: Take steps to educate families about coordination of benefits and how it can positively or negatively impact coverage of services. This can be done during the initial intake period, and also during annual benefit verifications.
Educate your billing team: Conduct regular trainings with billing and authorizations staff to ensure everyone on the team understands how coordination of benefits impacts authorizations and reimbursement. Encourage billing staff to be on high alert for COB denials, and consider a structured feedback loop to troubleshoot eligibility denial trends.
SUMMARY
Understanding coordination of benefits is an essential part of optimizing reimbursement for you and the families you serve. By understanding how primary and secondary insurance policies work together, you can ensure that clients are getting the most from their policies and reducing unnecessary out of pocket costs. You can also reduce your billing overhead costs and maximize reimbursement for the services you provide.
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