When you look at claim trends across outpatient care, one pattern keeps surfacing. Leaders report rising denial rates tied to front end issues, especially eligibility and coverage mix ups. Recent industry polling of medical group leaders shows that most have seen claim denials increase within the last year, and many point directly to registration problems and missing data as a root cause. In plain terms, if your team guesses wrong about who pays first, your revenue cycle slows down.
Why Coordination of Benefits matters for your clinic
From an operations perspective, COB is about avoiding avoidable work. When the primary and secondary plans are set correctly from the start, you see three concrete benefits.
- Cleaner claims. A significant share of denials in the United States comes from basic registration and eligibility errors, including incorrect payer order. Every time COB is wrong, your team has to touch that account again, sometimes more than once.
- Faster reimbursement. If the wrong plan is billed first, the claim can sit for weeks, then bounce, then require resubmission. When the order is correct, the primary plan adjudicates, then the secondary, then you can bill the patient if needed, no drama just sequence.
- Less friction for patients and staff. When COB is sorted out early, patients are not caught between plans that both say they are secondary, and your staff is not stuck explaining why a statement arrived that never should have gone out.
In a context where many clinics now rely on an AI powered front office and structured intake workflows, including platforms such as Solum Health, COB is one of the key data points that needs to be captured cleanly, stored correctly, and reused across calls, messages, and intake steps.
What Coordination of Benefits actually is
At its core, Coordination of Benefits is a standard set of rules that insurers use to decide which health plan pays first when a patient has more than one active policy. The goal is straightforward, limit total payments to the cost of covered services while avoiding both duplication and gaps.
Federal guidance describes COB as the process that lets health plans determine their respective payment responsibilities when an individual is covered by more than one plan, including Medicare or other coverage. In practice, that means the primary payer pays what it owes, then the secondary payer looks at what is left and applies its own benefit rules.
For your clinic, the important point is simple. COB is not a guess or a negotiation. It is a defined order of benefit determination, and if you understand that order, you can design workflows that respect it.
How COB works in practice
Behind the jargon, COB follows a fairly consistent pattern across payers. The specifics can be complex, but the structure is predictable.
1. Confirm multiple active plans
This can include employer coverage, coverage through a spouse or parent, government programs, or a mix of commercial and public plans.
2. Determine the primary plan
Industry rules typically favor the plan where the patient is the employee or subscriber over a dependent plan. For children covered by two parents, the plan of the parent whose birthday falls earlier in the calendar year often pays first. Medicaid is usually treated as a payer of last resort, and Medicare can be primary or secondary depending on employment status and other factors.
3. Establish secondary or tertiary coverage
Once the primary plan is known, other plans fall into place. Each secondary plan reviews the primary Explanation of Benefits and then applies its own coverage terms.
4. Submit the claim to the primary payer
The claim that goes out first must have accurate subscriber information, coverage dates, and site of service details. Any error here will echo through the rest of the sequence.
5. Apply the primary EOB, then submit to the secondary payer
Secondary plans rely on the primary EOB to calculate what they will pay. That is why missing or delayed EOBs can stall payment.
6. Keep COB records synchronized
Coverage changes frequently during the year, so COB data at intake can be stale by the time of the visit if you never recheck it.
Steps to adopt stronger COB workflows
If you want to tighten up COB handling this quarter, you do not need a massive project plan. You do need a clear sequence.
- Start by mapping where COB is asked today. Look at your phone scripts, online intake forms, and any pre visit workflows you already use. Document patient coverage questions in a structured way.
- Decide when COB will be verified. Many clinics now perform eligibility checks that support MRN crosswalk work and data matching, extending them to confirm primary versus secondary status, rather than waiting until after a denial.
- Script and train your front desk. Write consistent prompts so staff can explain why you ask about multiple plans and what happens if a plan is marked incorrectly, removing guesswork.
- Put technology to work. Use a platform combining call queue analytics for medical practices with a single unified inbox for calls, texts, and emails, so your team sees all insurance conversations in one place. Layer in patient reminder automation to make COB checks routine.
- Create an implementation timeline for clinic software that matches your capacity. Start with one site or service line and expand once cleaner COB reduces denials.
Common COB pitfalls to watch
- Outdated coverage data. Open enrollment or job changes happen but the chart still reflects last year’s primary plan.
- Ignoring secondary coverage because it feels confusing, leading to higher patient balances and more questions later.
- Inconsistent documentation. COB details written in free text notes are not visible to everyone who needs them.
- Lack of feedback loops. Revenue cycle teams see denial reasons but front desk teams never get that information in a usable format.
Quick FAQs about Coordination of Benefits
- What is Coordination of Benefits in simple terms? Coordination of Benefits is the process insurers use to decide which plan pays first and which pays next when a patient has more than one active health insurance policy.
- Who decides which plan pays first? The order is determined by standard industry rules, including whether a person is an employee or a dependent, the birthday rule for children, and federal rules that govern programs such as Medicare and Medicaid. The clinic does not choose the primary plan, payers do.
- How often should clinics verify COB? The safest approach is to verify COB at each new episode of care and whenever there is a known coverage change, for example after open enrollment or a reported job change.
- What happens when COB information is wrong? v Incorrect COB information often leads to claim denials or delayed payments. The claim may need to be resubmitted to the correct primary payer, which increases staff work and stretches your days in accounts receivable.
- How does COB affect what patients owe? If the wrong plan is billed first, the patient may receive a statement that does not reflect their true benefit structure. Accurate COB protects patients from being asked to pay more than they should.
A short action plan you can use this week
Review the last month of denials and flag any tied to coverage or eligibility. Update intake scripts so every patient is asked about other active plans, ensuring that the answer lands in a structured field. Work with your revenue cycle lead and technology partners to bake COB checks into your pre visit verification, not just back office clean up. As you expand automation, keep an eye on tools that align COB with a single front office view, such as an AI powered unified inbox and intake automation that integrates with your EHR and practice management systems. That combination delivers measurable time savings for staff and a smoother experience for patients.
