Enhanced Coordination of Benefits

Some Medicaid members with medically complex conditions who use high-cost services may also be eligible for private health insurance. We offer a combined high-tech, member-centric approach to provide targeted and enhanced case management and expand available benefits—with a dual focus on Medicaid claims expenditures and customer service.

What Challenges You

Your Medicaid program may not be receiving complete reporting of available and potential sources of private health insurance for members. Incomplete data and a lack of coordination with providers and insurers could mean erroneous denials by private payers for high-cost medical services and pharmacy-paid claims, and inadequate compliance with third-party billing requirements. At the same time, eligible members may not be accessing all available sources of coverage if they don’t know or fully understand that private health insurance and Medicaid work together.


Why Choose Us

We help Medicaid members, programs, and providers coordinate insurance benefits for members with access to private insurance—helping them access complete coverage while protecting Medicaid as the Payor of Last Resort. Our unique approach combines claims data expertise, analysis of available insurance sources, and individualized case management support.

As a result, members and their families have access to a broader range of services and providers—and peace of mind so they can better focus on treatment and care. Your Medicaid program could see significant savings—tens of millions of dollars annually—if private insurance covers significant costs for your Medicaid populations with disabilities and chronic conditions who use high-cost services. Providers can also experience higher reimbursement rates as a result of the private insurance payment.

How We Can Help

  1. 1

    We offer enhanced case management coordination, with a dual focus on Medicaid claims expenditures and customer service.
  2. 2

    For members and families experiencing serious health events such a trauma, transplant surgery, cancer diagnosis or a NICU stay, our case coordinators can identify available private insurance, navigate the private insurance-Medicaid relationship, and help ensure services are covered.
  3. 3

    We coordinate Medicaid prior authorization processes for medical and pharmacy services, ensuring private health insurance is considered when prior authorizations are granted and maximizing the use of available third-party payers.

Our Impact

Coordination, Where It Counts

With enhanced, one-on-one coordination for over 230 Medicaid members, we lowered the potential costs to a state’s Medicaid program by more than $60M in a single fiscal year.

Additionally, we helped one state’s Medicaid agency avoid an additional $14M in costs over two years, using expanded data analytics and case management services for Medicaid members with disabilities and chronic illnesses.