The most important thing to remember is that in managed care claims, the contract will control the claim. Any need to coordinate benefits between the contracted claim the and a third party claim will be specifically set forth in the contract. The same is NOT true of government claims. Medicare and Medicaid have their own rules related to he settlement of third party claims.
Sometimes you must look at the language within your State’s Medicaid Agency contract. Other times you need to examine the specific details of a Managed Care Organization (MCO) agreement. These contracts, although they are contracts with government or semi-government entities will determine the conditions under which the MCO will obtain some responsibility for the Third Party Liability (TPL) claim. In many instances, the Third Party Liability Administrator (TPLa) will take all the steps necessary for the MCO to properly control that TPL claim.
The top ways to move forward on TPL in the managed care environment are as follows
- The Patient’s contract specifically excludes and should deny any payments for services rendered while another option for coverage exists. In other words, if the TPL claim for Bodily Injury (BI) or Personal Injury Protection (PIP) insurance is available, the managed care contract is not permitted to step in and pay medical bills at all.
- The Patient has managed care through the state. That government / Medicaid provider may pay the initial claims, but will retain significant lien rights for reimbursement from any TPL payment in the future. The Patient must determine how to deal with the State payer’s reimbursement rights directly.
- The Patient with the TPL claim also has medical payment coverage through an MCO. In those instances the TPL responsibilities are delegated to the Managed Care Organization (MCO). This helps to lower medical costs by forcing adjustments down to the MCO rates, including capitation payments, and lowers the necessary lien on TPL benefits.
- The Patient and/or Patient’s dependents have available health or managed care coverage. They are not eligible for government health benefits/Medicaid/Medicaid MCO IF TPL or BI is available for said health payments. Until those TPL benefits are exhausted the health coverage should not be used. However if it is used (often happens) then the contracted payer retains a lien against the TPL proceeds.
Medical billing companies who do not see the TPL analysis often miss a number of steps in the process of securing TPL Lien rights for their medical providers. Don’t allow your medical billing staff to miss any steps in securing PIP benefits, BI Liens, Med Pay, or any other form of payment that can and will happen in the most common accident related claims. Attorney’s are adept at negotiating the doctors who treat their clients out of their money all the while having thousands of dollars available for payment of medical bills.