How well are States complying with Medicaid’s third-party liability requirements?

Medicaid is a joint federal-state program that provides health coverage to millions of low-income Americans. However, Medicaid is not supposed to pay for services that are covered by other sources, such as private insurance, Medicare, or workers’ compensation. This is known as the third-party liability (TPL) requirement, which ensures that Medicaid functions as the payer of last resort and avoids unnecessary spending.

The Office of Inspector General (OIG) recently conducted an audit of five States (Illinois, Indiana, Michigan, Ohio, and Wisconsin) to assess their compliance with TPL requirements. The OIG found that the States faced ongoing challenges in meeting TPL requirements, such as identifying and verifying other sources of health coverage, collecting and reporting accurate TPL data, and recovering payments from third parties.

The OIG also found that the Centers for Medicare & Medicaid Services (CMS) did not provide adequate guidance, oversight, and technical assistance to the States to help them address these challenges. The OIG recommended that CMS take several actions to improve the States’ TPL performance, such as issuing clarifying guidance, enhancing data quality checks, conducting regular reviews, and providing targeted training and support.

The OIG’s report highlights the importance of ensuring that Medicaid pays only for services that are not covered by other sources. This can help save taxpayer dollars and preserve the program’s fiscal sustainability. The OIG’s recommendations can help CMS and the States improve their TPL processes and outcomes.

How Other Party Liability, Inc. Can Help You Recover Medicaid Overpayments

Medicaid is a joint federal and state program that provides health coverage to millions of Americans who are eligible based on their income, disability, or other factors. However, sometimes Medicaid pays for services that are also covered by another payer, such as a private insurer, Medicare, or a workers’ compensation plan. This results in overpayments that Medicaid is entitled to recover from the other payer. This process is known as third party liability (TPL).

According to a recent report by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services, the Ohio Department of Medicaid (ODM) did not always identify and recover Medicaid overpayments from other payers. The report found that ODM did not have adequate policies and procedures to ensure that TPL information was accurate and complete, and that overpayments were promptly identified and collected. As a result, ODM missed opportunities to recover an estimated $51.6 million in Medicaid overpayments from other payers in fiscal year 2015.

This is where Other Party Liability, Inc. comes in. We provide TPL services to help state Medicaid agencies identify and recover Medicaid overpayments from other payers. We have the expertise, technology, and resources to handle all aspects of TPL, including:

  • Data matching and verification: We use advanced data analytics and verification techniques to match Medicaid claims with other payer information, and to verify the accuracy and completeness of TPL data.
  • Overpayment identification and recovery: We use sophisticated algorithms and rules to identify potential overpayments, and to pursue recovery from other payers through various methods, such as billing, coordination of benefits, subrogation, and cost avoidance.
  • Reporting and monitoring: We provide comprehensive and timely reports and feedback to our clients on the status and outcomes of TPL activities, and we monitor and evaluate the performance and effectiveness of our TPL services.

By outsourcing TPL services to Other Party Liability, Inc., state Medicaid agencies can benefit from:

  • Increased savings and revenue: We can help state Medicaid agencies recover more Medicaid overpayments from other payers, and reduce the amount of future overpayments, resulting in significant savings and revenue for the state and federal governments.
  • Improved compliance and quality: We can help state Medicaid agencies comply with federal and state laws and regulations regarding TPL, and improve the quality and accuracy of TPL data and processes.
  • Reduced administrative burden and cost: We can help state Medicaid agencies reduce the administrative burden and cost of TPL activities, and free up their staff and resources for other core functions.

If you are interested in learning more about our TPL services, please contact us today. We would love to hear from you and discuss how we can help you recover Medicaid overpayments from other payers.

Medicare Secondary Payer (MSP) NGHP Reporting Entities CMS Update Alert

CMS: NGHP Responsible Reporting Entities (RREs) that both Med Pay and
Personal Injury Protection (PIP) coverage should be included when reporting the No-Fault Insurance Limit (Field 61 of Claim Input File). As such, NGHP RREs must combine both Med Pay and PIP coverage limits for a policy when they are separate coverages being paid out on claims for the same injured party and incident under a single policy.

Health plans must continue to innovate claim systems and recovery modules, incorporating the OHI and MARx weekly and monthly update files into their claim mining Third Party Liability software.

Third Circuit Appeals Court slams the door on Plaintiffs attempt to allocate settlement

Third Circuit Appeals Court slams the door on Plaintiffs attempt to allocate settlement.

The Third Circuit court of appeals today expressly held that even though Plaintiffs counsel had received from a state court Judge a zero allocation of a settlement to Medicare’s conditional payment. Medicare none the less had a right to its Conditional payment under the MSP regulations.