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In the latter half of 2012, the business office of our hospital system had an odd request for our point of service locations. They asked if we could start collecting a new form when the patient enters for services, a form called COB or Coordination of Benefits, and the request was specific to only patients who had Blue Cross Blue Shield coverages yet not including Blue Cross Federal. When we asked how this new form was related to the patient’s identity, demographics, or revenue cycle, we were informed that by collecting this form at the point of service, we would allow our hospital system to receive payment 3 to 6 months earlier in many cases. This seemed reasonable enough at the beginning, but over time seems to have morphed into a strange march backwards in logic. To explain why, let us first look at what exactly a COB form is.
A COB form is needed in various situations when a patient may have more than 1 active health insurance plan. Examples of this are:
· You and your spouse are both employed and both have included each other on your policies.
· You or your spouse may be eligible for Medicare while still employed and coverage by a group health plan.
· A child up to age 26 whose parents are both employed and have family coverage under their plans.
· A patient is being treated for injuries sustained in an auto accident or a fall on a wet floor at a store (this falls under Subrogation rather than Coordination of Benefits, but as the forms themselves ask for this information, we will include the example)
The purpose of the COB form is to establish which payer will be primary and which will be secondary for the patient’s visit, and until this can be established, the payer may withhold payment until said form is completed and received from the patient. Thus we come to the primary problem with the processing of these forms. The patient is expected to complete this form annually, regardless if they have any other active coverage for their services or not. Additionally, the onus for these forms which originates between the patient and their insurers is falling outside either entity, and onto the health care provider, as that is where the payments are being held up. The law of natural consequences would indicate that a failure of either communicating the form, or completing the form would impact either the insurer requesting it, or the patient completing it. Why the provider is left holding the bag is something of a mystery.
While the extra burden on the front-end for the provider was initially minor, this metastasized from a single payer to three, and continues to grow with no end in sight. The thought of requiring and maintaining a stash of COB forms, one for each payer our institution is contracted with, at each workstation at each point of entry seems excessive. Unfortunately, when said payers were asked in a Joint Operating Committee meeting if we could collaborate on a single, universal form to be used for all payers, they refused. Their rational was they could not be expected to adjust to different forms and formats for each hospital system they are contracted with. The insurance companies did not have the man-power to make that sort of adjustment, although they somehow seem perfectly comfortable forcing the front-end of our hospital systems to do the same.
This begs the question, “Why is there not a universal standard form or system for this similar to the 270/271 eligibility, coverage, and benefit inquiry process under the HIPAA transaction and code sets?” We can only guess at the answer, but a good guess would be that those rules are intended for communications between providers, insurance, clearing houses and other health care adjudication processors. These guidelines were never intended for informational transactions between insurers and patients.
Finally, while it seems front-end areas are subsequently stuck with this extra burden, we are left with some options on how to implement it, and some ways may impact the patient experience better than others. While it may be tempting to provide the patient the form, a pen, and clipboard, and ask them to return when completed, coordinating benefits can be very confusing for the laymen who does not live, breathe, and eat these terms on a daily basis. Additionally, while the insurers claim to have sent copies of these forms to their subscribers annually, most patients tell us they have never seen these forms before. Accuracy can also be a problem, as many patients do not bring their insurance cards with them, or may be unable to read their policy numbers and transpose them correctly onto the form.
While more time-intensive, we have had much greater success completing everything except the signature on the form for the patients ourselves. After all, if the patient has been fully pre-registered, we already have all of the pertinent information completed and verified within our ADT system already. Ultimately, if we are going to go the extra mile for our patients, we might as well look good doing it. The COB form provides us an opportunity to educate patients a bit about their benefits, and affords them the opportunity to see us doing them a favor while lowering their anxiety as they present at our treatment facilities. Good customer service is all about lowing our patient’s anxieties, so while the COB form process itself seems like a backwards lemon, there is a chance with them to make some lemonade.
· Additional information about COB forms can be found here:
· A Medicare PDF “Getting Started with Coordination of Benefits” -https://www.medicare.gov/Pubs/pdf/11546-coordination-of-benefits.pdf
· Blue Cross of Michigan FAQ on COB -https://www.bcbsm.com/index/health-insurance-help/faqs/topics/understanding-benefits/coordination-of-benefits.html
· Article at Insure.com “How coordination of benefits works” - https://www.insure.com/health-insurance/how-coordination-of-benefits-works
A few years ago my father had surgery at a local hospital, and while I waited with my family in the waiting room, we gazed around the area, people watching, and paying scant attention to what was playing on the national news. That was, until, a story came on about hospital acquired infections and mortality rates. Now my wife, sister, and both parents all work in healthcare. So while the story itself did not raise our collective anxiety too much, it did spawn a very interesting discussion about what stations would be best to show in healthcare waiting areas. Here are some suggestions that came out from that discussion of 4 healthcare professionals who all work closely with patient waiting areas.
The national news is probably not the best choice. At first glance CNN or MSNBC would seem innocuous enough to please the vast majority of our patient base, but our focus on customer service should be to put our patients and visitors at ease. We want to lower their anxieties or at the very least distract them from the stressors they may be experiencing, and all too often national news is sensationalized in an effort to increase viewership. There have been very valid criticisms, especially recently, that political discussions, negative stories, and news agencies have been promoting fear. This is the exact opposite approach we should attempt as a healthcare organization. There is also a danger in those stations that repeat their programming every 30 or 60 minutes. A patient or family waiting will have an exact reminder of just how long they have been inactively sitting, and there is a reason most of our waiting rooms do not have a visible clock posted within them.
More successful stations include music channels, game shows, home improvement, history channels, biographies, and children’s programming. These tend to be more sedate in their content, yet interesting enough to hold the viewer’s attention without becoming so invested they experience an increased heart rate. Local stations that give local news updates can also be a viable alternative, especially when interspersed with children’s programs or game shows (And I will readily admit that I do not know where to place daytime soap operas on this list). Shows like Pawn Stars, Forged in Fire, and American Pickers are some of my personal favorites, and they can be quickly engaging to new viewers who have never seen them before, but are never so entrancing that patients are unhappy when their name is called or their loved one is released to go home.
Finally, if you have a waiting area with multiple televisions and separate areas, consider attracting visitors with similar interests. If all 3 televisions are tuned to the same station, the patients and visitors have no variety or choice. Alternatively if they can see one TV on a home improvement station, another on history channel, and the third on Disney, the feel like they can make an informed decision as to where they would like to spend their time. There is also something to be said for turning the volumes on the televisions low while turning on the closed captioning. Not only will this please your hearing impaired patients and visitors, but keeping the decibel level low helps to lower everyone’s anxiety as well, both visitors and employees. Lastly, consider putting the children’s channel as far away from your check-in desk as possible (kids can be loud, and difficult to communicate over).
Peter Hawkins, CHAM | Patient Access Scheduler Pre-Services
Tucson Medical Center
Peter has 18 years of healthcare experience