Coordination of benefits (COB) is a key component of any effective payment integrity program. But determining primacy for members with multiple plans and ensuring claims aren’t overpaid can be a complicated process. Whether it’s verifying employment status or sifting through complicated claims, COB takes significant time for peak accuracy. And while health plans focus on the intricacies of an effective COB strategy, many overlook the possibilities that a comprehensive prepay COB solution can offer as a valuable component.
Prepay or prospective COB takes effective COB a step further, eliminating the need to correct errors after the fact by pausing the claim process to confirm accurate information and proper order of benefits before payment. When done correctly, prepay COB has the potential to not only prevent overpayments but also to ensure accurate member profiles, augment cost avoidance, and determine primary payment responsibility sooner. All these things combine to lower provider and member abrasion and increase value.
While most, if not all, payers agree that there is significant value in prepay COB as part of an overall COB strategy, and to payment integrity efforts in general, taking prepay COB from a concept to reality remains somewhat mysterious for most plans. This may be due to a lack of clarity around the distinction between an asset and a solution, as well as common misconceptions surrounding how a full-scale prepay COB solution works and the value it can deliver.
The value of prepay COB
Prepay COB offers three major benefits: Administrative cost savings, speed, and long-term value.
Administrative cost savings
Perhaps the most obvious benefit of prospective COB is administrative savings. Rather than deploying talent and incurring significant costs to recover funds from a provider that was paid in error, prepay COB avoids the incorrect payment in the first place, reducing the effort required to enable payments based on an accurate order of benefit determination. By pausing the claim process, plans save significant costs that would otherwise be spent chasing down overpayments. Removing the need to recover medical spend, prepay COB reduces the burden on plan resources and providers and helps plans to streamline administrative efforts up front, while creating capacity to redeploy talent to other valuable work.
Speed
As a result of this, eliminated need to chase down payment, and speed becomes a significant benefit of prepay COB as well. To satisfy prompt-pay regulations, speed is a crucial benefit for avoiding penalties or being able to recoup payments at all. For example, in Texas, plans are only permitted to recoup payments from providers within a six-month window. If that time expires, the opportunity to achieve payment accuracy is over. Prepay COB can help to capture maximum value before time runs out.
Long-term value
Administrative costs and speed to value are important on their own, but prospective COB also creates a system that inherently provides perpetual value. Over time, prepay COB helps save costs by running on groomed and accurate data, which is both up-to-date and infused with expertise tailored to a particular health plan. It isn’t just about executing on a set of linear steps—prepay COB done correctly is a sophisticated process that requires understanding when, how, and where to use data.
For example, one national plan that adopted prepay COB was able to save an estimated $48 million in 2025 alone and create a sizable feedback loop by applying insights to inform future strategies. This plan was also able to realize savings on more than 99% of all claims identified for prepayment.
Prepay COB in action
Prepay COB can be applied in a variety of different scenarios. A few specific prime candidates include:
- Medicare other health insurance (OHI) for disability: Identifying Medicare for members entitled based on disability is especially valuable because these cases often lack leading indicators such as age and defined medical conditions. Without these triggers, disability-based Medicare coverage can remain hidden, leading to incorrect primary liability for the health plan. By confirming this coverage and determining the order of benefits before a claim pays, plans can ensure accurate COB, prevent unnecessary payments, and shift costs appropriately—delivering savings while protecting benefit integrity.
- Newborns: Automatic newborn coverage covers a newborn for a set period under a parent’s existing plan. This ensures immediate coverage at birth, even before the child is formally added to a policy. Consider a scenario where there are newborn multiples. Leveraging a prepay COB solution may enable a plan to pause a claim for one newborn, correct the order of benefits, and apply that finding to the remaining siblings, assuming the same dual coverage applies. In scenarios such as these, prepay COB processes can ensure timely payment to providers without sacrificing accuracy.
Going beyond data assets
Complex data goes hand in hand with complex claims. However, there’s a common misinterpretation that prepay COB is simply the ability to execute regular COB processes using data sources. In theory, having access to data assets should provide enough information to be able to pause claims and conduct a COB review, but in practice, this often proves to be difficult to scale. Plans can’t pause every single claim that comes through and can easily be overwhelmed by the need for administrative resources, expertise, and data cleansing to make prepay COB work effectively.
Having good data is just one piece of the prepay COB puzzle. A complete review requires experts to not only verify data but also have the expertise to understand where there are gaps and how to interpret the data once secured.
An effective prepay COB strategy builds, anticipates, and navigates a process that is often nonlinear. Being able to capture savings prepayment isn’t just about figuring out if there is another policy that covers the member, but may also require a close examination of variables such as:
- Working status of the member
- Employer group size
- Benefit exhaustion
- OHI-related nuance
Executing prospective COB well means being familiar with all of a claim’s components and knowing what to look for, not just leaning on data assets.
Setting up for success
Going above and beyond to execute prepay COB hinges on having strong components and a strong team. Consider whether your plan can: perform data enrichment, prioritize claims eligible for prepay COB, and incorporate a true pause-and-review prospective functionality.
Perform data enrichment
Just one dataset is not enough for identifying payment responsibility and determining primacy, and manually managing this data is unscalable for many. Consider investing in a solution that can detect areas where data is missing, incorrect, duplicated, or outdated, and leverage the expertise of COB data professionals to rectify and enhance the dataset. Data may need to be supplemented with a range of public and proprietary sources to close gaps.
Prioritize claims eligible for prepay COB
It isn’t feasible to review every claim prospectively for COB, nor to comb through vast entitlement datasets. An effective prepay COB solution should analyze data to determine priority, incorporating machine learning to identify possible instances of primary other health insurance coverage.
Keep it human
As much as artificial intelligence and automation can fuel speed to processes, a complex area like prepay COB requires human expertise and decision-making. Auditors can uncover crucial details to accurately establish the order of benefits that would not be possible with technology alone. Remaining up-to-date and compliant with various COB requirements, including those codified in the Medicare Secondary Payer Act (MSP) and the National Association of Insurance Commissioners (NAIC) guidelines, as well as state laws, makes talent even more valuable.
Prepay COB is a valuable component of an overall payment integrity program and any COB strategy. By pausing claims and determining the accurate order of benefits before payment, plans can explore a litany of benefits. They save on administrative costs, speed along the process, and gain incremental value over time by refining data and limiting provider and member abrasion. While it takes more than a robust data resource, investing in the right partner, solution, and experts can provide significant return on investment.
About Naomi Murphy, J.D.
Naomi Murphy oversees operations and product strategy for Cotiviti’s COB Validation and Data Mining solutions, delivering streamlined value generation for clients. A versatile operations leader, Naomi has a demonstrated track record of delivering operational excellence, leveraging predictive analytics, and accelerating growth.
