The vast majority of Medicaid improper payments occur due to antiquated data systems that result in eligibility errors. As the program has grown, identifying primary commercial coverage, also known as Third Party Liability (TPL), has become increasingly more complex and challenging. By law, Medicaid plans...
Since Medicaid’s inception in 1965, the program has expanded to become the largest provider of healthcare coverage in the country. As the member population size has grown, Medicaid third party liability (TPL) efforts and fiscal responsibility have been reoccurring issues. To protect Medicaid’s solvency, there...
Identifying third party liability continues to be a challenge under the coordination of benefits for Medicaid plans. By law, plans are payers of last resort so whenever beneficiaries have other active coverage (OHI), those third parties should pay first. Currently, Medicaid plans are required to...
Medicare and Medicaid accounted for $40 billion dollars in improper payments last year and the Medicaid program has been on the GAO’s High Risk List since 2003 due to inadequate fiscal oversight. However, last month CMS announced that the agency achieved the lowest improper payment...
The federal government must quickly move away from the "Pay and Chase" model where Medicaid routinely makes improper claims payments (those that were the liability of primary insurance plans), then retrospectively identifies the claims with third party liability. To make this change, the government must...
When ProTPL discovers other health insurance, you can reverse the latest claim and ensure that future claims, whether pharmacy or medical, aren’t paid in error. Discovering other health insurance fast, triggered by Pharmacy claims, allows you to intercept the medical claims, such as office or...
Why GAO Did This Study During fiscal year 2013, Medicaid - collectively funded by states and the federal government - delivered health care insurance coverage to over 70 million people at an overall cost of about $460 billion. Our lawmakers generally established Medicaid as the health...
Recently, I got into a discussion with a state Medicaid TPL director about RFPs for third party liability cost avoidance work. I feel that our cost avoidance solution would greatly benefit state-run plans, but RFPs are nearly always written for a single vendor to handle an assortment of...
In the previous post, I discussed how ProTPL uses Rx claims to "trigger" cost avoidance, not only for pharmacy claims, but for medical claims as well. In the case study that started in 2012, we see how this is put into practice. There are two key...
When ProTPL discovers other health insurance, you can reverse the latest claim and ensure that future claims, whether pharmacy or medical, aren’t paid in error. Discovering other health insurance fast, triggered by Pharmacy claims, allows you to intercept the medical claims, such as office or...