As part of the prior postings, we went over the 3 main "practices" states ought to adopt in order to cost avoid and save taxpayer money. For states to possess a genuinely effective TPL plan, prompt identification of any additional coverage is needed during the time of Medicaid registration. Also, cost avoidance discovery must be instant whenever claims are made, and claims that were paid in error should be recovered swiftly. The ideal situation is one through which federal regulations and state laws merge to establish a genuinely comprehensive DRA Policy that recognizes additional health insurance coverage with speedy recovery of each claim.

A Complete TPL State Program Contains:.

The active identification of other coverage at enrollment.
The quick avoidance of the cost of claims.
The ability to recover claims paid incorrectly.

If embraced by all states, the preceding suggestions lend towards the meaningful recovery of money for state Medicaid agencies, along with the saving of money. The onus of these economic times is to do more with less money. And, as the Affordable Care Act (ACA) comes to be effective on Jan. 1, 2014, Medicaid claims are going to expand. That's why bolstering DRA-compliant legal language within all states will lend to improved cost recovery and additional savings for the healthcare of the whole country.

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Healthcare Cost Containment for States

The practice of an MCO or Medicaid charging a medical insurance provider is backwards. It's absolutely the obligation of the commercial insurance provider to make the preliminary payment, to ensure that insurance coverage claims are not delayed, which is the case when Medicaid or a Medicaid MCO does the initial billing.

It only makes sense that insurance providers should be required to handle claims quickly and make timely payments regardless of whether the claims are electronic or on paper. So long as an acceptable timeframe is utilized, an MCO or a state Medicaid agency ought to have the right to identify alternative claim processing approaches in order to maintain the integrity, and consequently the speed, of the entire process. Eventually, this implies that federal laws are complied with, timetables are developed on retrospective recoveries by state Medicaid agencies, and Medicaid funds aren't left in a state of limbo... Read More

State Practice Two: Indentifying TPL Insurers

This is the second blog post in a 3 part series through which I discuss exactly what measures states really should adopt to develop an efficient TPL scheme. In part one, we reviewed the necessity for insurers to cooperate in the active identification of other insurance coverage. With this installment, we discuss exactly how to receive the records required for healthcare cost containment and, more significantly cost avoidance. Read More

TPL State Plan Recommendations Part 1: Get insurer Cooperation

The only means for states to have an efficient third party liability plan is through efficient discovery of additional coverage. Additionally, when claims are generated, cost avoidance must be prompt. What works best is when the federal directives and state laws mesh to form a totally thorough DRA plan that recognizes additional health insurance coverage with prompt recovery of each claim.

A thorough state third party liability program must contain:

• The active detection of other insurance coverage at Medicaid registration.
• The prompt avoidance of the cost of claims
• The ability to recuperate claims paid incorrectly

Creating better TPL plans necessitates that states gain from the missteps of other states. Read part 1 of a three part series that summarizes procedures that can be adopted by states to achieve increased TPL recoveries and therefore enhance cost savings...   Read More

Regulations Regarding Third Party Liability and Payers of Last Resort

In 1934, FDR signed the Social Security Act into law. One of the law's statues specifies "... that the State or local agency administering such plan will take all reasonable measures to ascertain the legal liability of third parties ... to pay for care and services" offered to Medicaid beneficiaries.

Basically, it denotes that Medicaid becomes the payer of last resort (PLR), a term also named third party liability (TPL), or the Coordination of Benefits (COB). Essentially, Medicaid pays last, and if a Medicaid member possesses other insurance policies, such as insurance through his/her employer, that insurance provider pays first then Medicaid pays any remaining costs.

As much as 10 percent of the Medicaid members throughout the country keep additional insurance beyond Medicaid, which is deemed TPL. Varieties of TPL include employee insurance, Workers' Compensation, Medicare, COBRA health insurance from previous employment, casualty insurance, dental insurance, eye insurance and insurance to cover prescription costs....    Read More