Medical Billing

# COB in Medical Billing: Rules for Insurance of Patients in Coordination of Benefits Explained

- September 22, 2022
- Posted by Kristen Edwards

22 Sep

The coordination of benefits is defined by the Centers of Medicare and Medicaid Services as the process by which the patients are allowed to choose who is responsible for their financial medical liability or insurance. This means that through COB, CMS permits patients to have more than one payer or insurance provider. However, through COB, providers are also prevented from claiming the same services by multiple insurance providers and claim a large reimbursement against the service rendered. Therefore, COB determines which payer will be secondary, primary, and so on.

## What is COB in medical billing?

Precisely, coordination of benefits establishes domains of working for two or more than two insurance companies to have a fair share of reimbursements when both plans cover a patient.

source:choice.com.au

Here, a question that commonly arises is why there could be a need for another insurance plan for a patient when the treatment is covered already by an insurance payer.

The answer would specify the secondary coverage plan that would come in handy when there’re out-of-pocket costs of treatment. This may include treatments that are not covered by primary insurance coverage. Hence, COB decides which insurance will be secondary and which one would be primary that automatically paves the way for billers to claim the right payers.

### How does cob in medical billing work?

The main purpose of the coordination of benefits is to make the payment procedure easier for the patients. When a patient uses the coordination of benefits, the primary insurance company will be first responsible for the treatment costs. Then if the treatment is covered under the insurance plan of the patient, the secondary insurance company will be responsible to pay the remaining 100% costs of the treatment received in any time period. No matter how many insurance plans you have, neither of them will go beyond 100% payment for the total healthcare services. This means it is impossible to receive double benefits when you have more than one insurance plan.

### Rules associated with coordination of benefits

COB guidelines and rules vary depending on multiple factors. They include the state you live in, the type and size of your insurance plans, and also the state that you are listed in as many states have their own set of rules. In addition, large employers also have their own rules for COB in place. Some common rules with the common organization include;

- Medicaid and Medicare – When a patient has multiple sources for medical health insurance coverage, CMS will only pay the last remaining payable amount. However, Medicare can be a primary or a secondary payer depending upon the circumstances. If the other payer is a small business, it can work as primary and vice versa.
- Worker’s compensation – If a worker is covered by their employers, then the worker’s compensation package would be responsible first and whether it is Medicare or any other insurance company would fall secondary.
- Employer-sponsored plans – Multiple payer situations also occur when you and your spouse have separate insurance plans. In this case, your employer-sponsored insurance plan would be first to look for as primary and your spouse payer will be secondary.

source:arcbenefitssolution.com

- Private Health Insurance Plan or Veterans Administration (VA) – VA actually is not considered a medical health insurance plan by CMS. They bill their claims to public or private health insurance providers for supplies, prescriptions, services, and care. In case you have a VA plan that doesn’t work for you, you must consider your spouse’s medical health insurance plan as your plan.
- Military coverage and other common health insurance coverages – Tricare; Military health coverage is a secondary healthcare plan for care services – but not always. Tricare supplement, specified federal government programs, and state crime compensation programs take Military coverage as the primary payer. Also, for the military forces, if they are hurt, Military coverage is the only option that they are left with.

### The system of COB in medical billing

To understand the process, here’s an example to figure the process for coordination of benefits;

Suppose that you have taken treatment and the billed amount is up to $150. The primary insurance plan chose to pay $50 from the original billed amount as they may not cover the reimbursement for the rest of the treatment. Here is the time when your secondary insurance comes into play. They will pay 100% of your remaining healthcare cost. However, the healthcare services coverage restriction lies here as well. In case the bill is left with the payable amount, this will be the out-of-pocket cost that you have to pay which both the insurance didn’t cover.

This may sound great that there will be the least amount that you need to pay out of your pocket. On the other hand, this is also the case that you have to pay the premiums for both the insurance companies throughout your plan period. In addition, in the case of a couple, if they both are employer-sponsored, then they can go for both options.

### Understanding Coordination of Benefits in Healthcare Insurance

Navigating the world of healthcare insurance can be complex, particularly when dealing with multiple insurance plans. One key concept to understand in this scenario is Coordination of Benefits, commonly abbreviated as COB. Whether you’re a policyholder or a healthcare provider, grasping the intricacies of COB in insurance is crucial for optimizing your coverage and minimizing out-of-pocket expenses.

### Coordination of Benefits in Medical Billing

In the context of medical billing, coordination of benefits is a critical step that ensures the correct processing of claims. The primary insurance plan is billed first, and once it has processed the claim, the remaining balance can be submitted to the secondary insurance for possible additional coverage.

Healthcare providers must be diligent in determining the order of payers to streamline the billing process and prevent delays. This involves verifying the patient’s coverage details and understanding the COB rules as stipulated by the insurance policies involved.

### Coordination of benefits for dependents

COB gets challenging when there are dependents involved in healthcare plans. Look at these examples that show how the coordination of benefits is beneficial and efficient for children and dependents.

### The Importance of COB in Healthcare

The significance of COB in healthcare extends beyond just the billing process. For patients, it means maximizing their healthcare benefits and reducing out-of-pocket costs. For healthcare providers, it translates to a more efficient revenue cycle management and fewer billing complications.

Moreover, COB regulations, as defined by the Health Insurance Portability and Accountability Act (HIPAA), provide a framework that protects patient information during the coordination process. This ensures that sensitive health information is handled with the utmost confidentiality and security.

source:flatworldsolutions.com

If a child has a divorced parent(s): When a child is raised under one parent, it is a firm rule that the child will be covered under the insurance company of the custodial parent. In situations where the divorced parent decides to remarry, then the step-parent secondary insurance provider may cover the child.

When a child is covered by the insurance of married parents: In this condition, when a child has dual coverage, the rule applies to the first birthday parent. This means whichever parent’s birth date comes first, they will be responsible for the primary coverage of the child. The other will be considered secondary.

When a female child is under 26 and gets pregnant: The coverage for children under 26 (unmarried) remains under their parents as stated above. Rules change in the case of a newborn when children are married. The coverage responsibility will be under their parent’s insurance company, not under their grandparents.

### What is COB in Insurance?

Coordination of Benefits (COB) is a process used by insurance companies to determine the financial responsibility of each plan when an individual is covered by more than one health insurance policy. This process is essential to avoid duplication of benefits and to ensure that the claims are paid correctly and efficiently.

The rules of COB outline which plan pays first (primary) and how the remaining benefits are calculated when claims are made to more than one group plan. This is especially common in scenarios where, for instance, both spouses have coverage through their respective employers, or when a child is covered under both parents’ insurance plans.

### Conclusion

Understanding the concept of COB in insurance, and its application in medical billing and healthcare, is fundamental for all parties involved. It ensures that medical expenses are covered appropriately and that benefits are utilized to their fullest potential.

By familiarizing yourself with the COB process, you can navigate the complexities of having multiple insurance plans with confidence. Whether you are a patient seeking to understand your coverage or a healthcare provider aiming to optimize your billing practices, COB plays a pivotal role in the healthcare insurance landscape.

For patients, it’s important to communicate with your insurance providers to understand how your benefits will coordinate. Be proactive in providing complete information about your insurance coverage to healthcare providers to facilitate the COB process.

Healthcare providers, on the other hand, should ensure their billing staff are well-trained in COB procedures to handle claims accurately. Investing in quality billing software or services that can automate and streamline the COB process is also beneficial, reducing the likelihood of errors and improving turnaround times on claims.

The coordination of benefits is more than just a bureaucratic step; it’s a strategic approach to managing healthcare costs effectively for all parties involved. By ensuring that the benefits from multiple insurance plans are utilized efficiently and without overlap, COB helps to maintain the integrity of the insurance system and provides a clear path for claim resolution.

In summary, COB in healthcare is a critical element that requires attention to detail and an understanding of insurance policies. Whether you are dealing with COB in insurance, coordination of benefits in medical billing, or COB in healthcare, the principles remain the same: to ensure that every party pays its fair share and that the insured individual receives the maximum benefit available.

As the healthcare landscape continues to evolve, staying informed about COB and its implications will be increasingly important. It’s a safeguard that benefits everyone, from the insured to the insurer, and is a key component in the efficient operation of healthcare services. With a professional grasp on COB, you can navigate the complexities of insurance coverage, ensuring that you or your patients are always in the best position to receive the care needed.

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