State Medicaid Third Party Liability Cost Avoidance Q & A

29 Jun State Medicaid Third Party Liability Cost Avoidance Q & A

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 TPL functions. This myopic approach is excluding states from saving millions in third party liability cost avoidance.

We do not claim to be an all-inclusive TPL solution. While our process mitigates the need to pay & chase, there is always going to be some recovery work. All of our current customers take a “layered” approach combining multiple data sources, vendors & processes to achieve an inclusive TPL program. They load the least expensive discovery vendor first followed by the second least expensive and so on. All of the OHI vendors have gaps in coverage identification especially Pharmacy which has historically been the most difficult to collect. We would expect that state-run plans would have a similar loading process including the loading of Pharmacy OHI collected from providers and PBM’s as they too must also provide coverage information to OHIO.

The following is a breakdown of some questions that were presented to Syrtis regarding our third party liability cost avoidance service:

ProTPL relies solely on Rx claims. If no Rx claim is ever submitted, no third party liability cost avoidance will be achieved for other submitted claims.

Correct if a Rx claim is not submitted by a recipient we will not be able to identify coverage on that individual for purposes of cost avoidance on other claims; However, as I mentioned above, ProTPL was never designed to be a primary or a full replacement OHI discovery solution. Here are some advantages our process has over other vendors:

– By “plugging-In” our OHI discovery solution to your current processes, you can expect a 25% increase in cost avoidance savings. I am certain that if we ran a quantitative Rx claims analysis for your plan’s members we would find OHI data you do not currently have.

– We provide active coverage on utilizing members within 24 hours of receiving the claim information from our customers making it useful actionable data and in many cases for more than just cost avoidance.

– Using Rx claims to “trigger” OHI discovery gives us the ability to hone in on utilizers as opposed to all your members blindly. In other words, we check (and you pay) only for data that you can use.

– Many states get waivers and write off Rx claims completely due to the misconception that Rx OHI data is impossible to attain. This is no longer the case.

ProTPL is designed to give our customers a leg up on cost avoidance. Our solution is a “FIRST STRIKE CAPABILITY” to help reduce and eliminate the retroactive pay and chase programs. It can’t at this point totally eliminate the expensive recovery programs just help to reduce the amount of the recoveries…

Termination dates are derived not truly validated thus may incorrectly cost avoid claims because terminations not processed timely.

Termination dates are not derived they are “open”.  In other words eligibility/coverage is considered active until a COB claim at the POS is rejected because the coverage is termed. When this happens, the Pharmacy POS can use the proper designated over-ride code and the member/recipient is served. The following day the overridden claims are reprocessed to ensure the coverage has expired and the pharmacies are doing their job correctly. As a point of interest our largest client processing 600,000 claims a month will see less than 50 overrides a week.  It’s a very simple and easily managed process.

The solution does not account for retroactivity. In our state, we match with Medicare 3 times a month. The recovery our pay and chase vendor finds is because Medicare coverage is granted RETROACTIVELY. So what happens is at the time of service no Medicare coverage exists. Then the next month, Medicare coverage is granted for prior months. Even if had 100% real time verification with every carrier in the country, still would have some pay and chase because of retroactivity.

ProTPL does account for retroactivity on your utilizing non-Medicare members for both pharmacy and medical claims because we do provide coverage start and end dates with our cross walked medical OHI. On the pharmacy side several of our customers will reverse the high dollar “trigger “ claim and any previous claims on the individuals will be sent to the recovery vendor to recovery if it passes their dollar threshold. On the medical side you can go back as far as the coverage will support….

Medicare Dual Eligibles are a different story. All of our customers will pre edit the files they send us and eliminate claims from individuals 65 and older. We make that suggestion up front. The opportunity of finding active OHI on that population is significantly less and not worth the expense using our process. You already have the most effective solution for dealing with Medicare Dual’s.

If a state moves to 100% managed care from day one, your product would benefit the managed care plan not state Medicaid agencies

States can see a tremendous benefit and we offer a free proof of concept to prove it to you…In Tennessee we process over 250,000 claims a month and will find on average 12,500 individuals they do not have primary coverage information on each month. Keep in mind this is after these same individuals have gone thought all the other vendors discovery processes…

– We find what they can’t because they do not have the Data or the ability to deliver the data the way we do

– We have a much different approach / business model and States have a very hard time seeing that because of the RPF rules and process.

Just as a point of interest, ProTPL has qualified for single source off cycle awards due to the unique nature of the database and our exclusive access to the data for purposes of OHI discovery for payers of last resort. We would be happy to respond to any questions you may have during the development of your RFP to include solutions like ProTPL. So let us do a proof of concept data run for you and let you see exactly what you are missing in Medicaid third party liability cost avoidance….