Member & Provider Services Unit: Coordination of Benefits

% of Medicaid members in the monthly data match who had new or updated commercial insurance policy information

41.3%Sep 2020

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Notes on Methodology

  • United Health Care (UHC)
  • Blue Cross Blue Shield of Vermont (BCBSVT)
Story Behind the Curve

Data matching uses data files required by State of Vermont Statute: 33 V.S.A. § 1908 Medicaid; payer of rights and shall not charge the Agency or any of its authorized agents fees for the processing of claims or eligibility requests. Data files requested by or provided to the Agency shall provide the Agency with eligibility and coverage information that will enable the Agency to determine the existence of third-party coverage for Medicaid recipients, the period during which Medicaid recipients may have been covered by the insurer, and the nature of the coverage provided, including information such as the name, address, and identifying number of the plan.

These data files are "matched" with the insurance panels captured in the DVHA's ACCESS system.  ACCESS is the repository of a member’s insurance data and is transferred to the payment systems. An "insurance panel" is a screen within the systems that contains the member’s policy and group numbers, for their primary insurance. This includes policy holder and family members covered. By matching the ACCESS system’s information against data received from an insurer, DVHA is able to capture missing or incorrect information. When ACCESS is missing "other" insurance info, a provider’s claim will be paid by Medicaid incorrectly. The correct information once added to ACCESS will re-direct a request for payment to the other insurer, and Cost Avoid any future claims. Currently, all updates to insurance screens "panels" in ACCESS resulting from data matching are manually done.

The Coordination of Benefits (COB) Unit currently receive between 2500 to 5000, sometimes more lines of data per month from United Health Care and BCBS of Vermont. The file’s come in monthly, the data is then reviewed by Coordination of Benefit Program Consultants for appropriate entry and updating.

Correcting and adding new beneficiary’s "other insurance" information, in part through data matching efforts with insurance companies, ensures that accurate insurance billing information is identified and recorded in Medicaid systems.  This decreases Medicaid costs, since the correct insurer pays, and maintains Medicaid as "payer of last resort". This is identified as Medicaid Cost Avoidance. The Medicaid Third Party Liability Cost Avoidance in 2017 was more than $130 Million, as stated data matching plays a part in this savings. 

In February 2019, BCBS continued to have a system issue producing a correct file.  BCBS has since corrected the their system and the SOV successfully uploaded the January data and COB started entering the data on 03/14/2019.  SOV and BCBS have come to an agreement starting April 1, 2019 the file exchange will be placed back on a regular schedule, the missing data from February 2019 will be on the next file along with March 2019 data. 

In May 2019, reduction of BCBS total number received in the match is due to the file being ongoing and the State of Vermont now has all members accounted for and will only received updates from BCBS going forward.

In August 2019, the data point was 100% because the United Health Care data was not available for review due to the files being switched to a different location (Global Scape instead of the State of Vermont SFTP site) .  This caused delays in uploading and the files were not received in time to process during this reporting period.  The data for UHC files in September 2019 included files for both August & September 2019.

Reason for the increase of BCBS of Vermont Data Match numbers; The Data Unit reviewed older data provided and found there was a specific data range and eligibility span that was missed in the initial scrubbing provided by DXC. 

No BCBS numbers to report as there was an error in reporting.  BCBS is currently working on getting corrected file which will include the new 2020 enrollment data.  Next month’s scorecard reporting should reflect 2 months, Jan/Feb. 2020.

March 15, 2020 BCBSVT counts include February 15, 2020 numbers as we had file exchange issue last month

BCBSVT has increased in April due to previous files having discrepancies, due to the discrepancies this has led to more updates.

Last updated:  10/15/2020


COB Recovery unit that reviews data matching is a team of 4 employees. 1 of the employee is the lead during the initial review who then disperses the report to the other employees.  We have found that by using staff talents within the group typically works best.  Longer term employee may offer additional assistance to the other staff which then leads to better group discussion.  This group works well as a team, they offer to help others who may have fallen behind due to other job duties and staff being out of the office.  Our main goal as a team is to get all data entered by month end, to reach this goal we all pitch in, and work together while taking all of our other duties into consideration.

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy