Case Study: Regional commercial health insurer achieves $4.66 PMPY savings and >250% ROI with Optum Coordination of Benefits solutions

How a regional carrier generated 250%+ ROI and increased yearly collections by $500,000 with comprehensive coordination of benefits (COB) solutions

Regional Commercial Health Insurance, a regional commercial health plan covering roughly 500,000 lives with about $2.5 billion in annual claim spend, needed to better identify primary coverage sources across its commercially covered population. The plan engaged Optum to supplement existing vendors with Coordination of Benefits services, targeting both prospective cost avoidance and retrospective recovery to uncover alternate primary coverage and reduce erroneous payments.

Optum implemented an end-to-end COB solution—using a frequently refreshed, multi-source data lake (medical, pharmacy, dental, vision, behavioral health), machine‑learning matching, NAIC rules, and real‑time carrier pings—to verify coverage with ~99% accuracy in a second‑pass position. In the first six months Optum’s solution produced >250% ROI, more than $500K in increased yearly collections, and boosted the plan’s savings by $4.66 PMPY ($1.26 PMPY prospective cost avoidance and $3.40 PMPY retrospective recovery).