Molina Healthcare Coordination of Benefits Case Study

This case study details the collaboration between Molina Healthcare and CAQH to enhance Molina's payment integrity program through a coordination of benefits (COB) solution. The objective was to identify overlapping health coverage prior to claims payment, thereby avoiding unnecessary recovery costs and minimizing member abrasion. The previous manual COB processes were labor-intensive and inefficient, prompting Molina to seek a more effective strategy. By automating these processes and utilizing the CAQH COB registry, which contains eligibility information for over 235 million members, Molina achieved significant improvements. The results indicated that COB accounted for 60% of Molina's payment integrity savings, with 90% of these savings derived from cost avoidance. The implementation of CAQH data allowed for a real-time eligibility check, leading to an eightfold increase in total savings while minimizing the impact on internal resources. This case study illustrates the effectiveness of leveraging validated COB data in optimizing healthcare payment processes.