Level Up Your TPL: Working to Enhance Medicaid Member Benefits and Maximize State Savings

In recent years, the Affordable Care Act and COVID-19 Public Health Emergency (PHE) Medicaid protections have expanded health insurance for millions of Americans, and many state Medicaid programs have experienced significant growth. While expanding Medicaid coverage has resulted in better healthcare for many, there may be health insurance benefits that Medicaid members are missing out on, which may cost state Medicaid programs millions of dollars in potential savings.

Third Party Liability (TPL) refers to a requirement that Medicaid must be the payer of last resort, or “by law, all other sources of coverage must pay claims under their policies before Medicaid will pay for the care of an eligible individual.”1

Unfortunately, many people with Medicaid coverage are not aware that they may also be eligible for other forms of coverage, including Medicare, employer-sponsored insurance, or other private insurance. As a result, individuals may be missing out on available benefits, and the costs of these missed benefits may be shifted to state Medicaid and other health and human service programs.

Become Proactive and Avoid “Pay and Chase”

States are required to take reasonable measures to identify potentially liable third parties and process claims accordingly.  When staff and resources are limited, states may be challenged to identify and coordinate other benefits up front and may rely on “pay and chase” activities. In other words, Medicaid has already paid for services, and states then must chase reimbursement from the actual liable payer. It can be an extremely time and resource-intensive process that may end up costing the state additional money. What’s more, Medicaid members, often those who are medically complex, miss out on key benefits.

So, what can be done to better solve that problem? States need to be able to identify and coordinate liable third parties at the beginning of the process, which results in more accurate Medicaid payments and recoveries, less administrative red tape, and most importantly, more financial security for Medicaid programs to support members who need their coverage most.

TPL should not be an afterthought. Engaging TPL services from the beginning of the Medicaid eligibility process to identify and successfully enroll eligible Medicaid recipients into Medicare, private, or other forms of insurance helps ensure recipients access all available benefits and states access all TPL savings opportunities.

Ensuring a Win-Win-Win

ForHealth Consulting™ at UMass Chan Medical School offers specialized TPL services, integrating Medicaid Eligibility processes with advanced data analytics and customized member support, to identify and secure enrollment for members in third party benefits.  Our experts possess the knowledge and expertise to help pinpoint Medicaid members who can enroll in other forms of insurance, potentially saving states millions of dollars. ForHealth Consulting wants to help states “level up their TPL” by being as proactive as possible from the start.

Our TPL services focus on two areas: Medicare Eligibility Enhancement, which aims to maximize Medicare benefits for eligible Medicaid members, and Enhanced Coordination of Benefits, which helps Medicaid members with medically complex conditions access and coordinate private insurance benefits.

Implementing this “level up” strategy provides a “win-win-win” for members, providers, and states: expanded coverage for members; an opportunity for providers to receive increased reimbursement rates/payments from other insurers; and cost and resource savings for states.

The ForHealth Consulting Difference

ForHealth Consulting takes a different approach in helping states achieve these wins. We go beyond traditional TPL. We have developed, customized, and advanced data mining and analysis processes that, in some instances, use data sets not traditionally used in TPL processes to achieve new results. We also work closely with members, providing customized support to help them understand other sources of coverage that states may have missed on their own, navigate enrollment processes, and break down barriers to securing and maintaining TPL. 

We ask the questions, “Why is a member not covered, what potential coverage opportunities may be out there, and what can we do to get coverage in place?”

ForHealth experts can provide added resources and enhanced analyses for states to uncover and access untapped pockets of opportunity. Everything we do supplements and complements what states already have in place and is customized to meet each state’s specific goals—and our fees are based on the results we achieve for the state.

The proof is in our outcomes: 

  • We have helped one state realize over $82 million in additional TPL cost savings since FY15 by identifying previously missed Medicare coverage among Medicaid recipients.
  • In another state, we have identified 15,000+ missed Medicare records since FY10, as the third “come-behind” review to existing state and vendor Medicare identification processes.
  • Our Medicare Enrollment activities have achieved a 96% Medicare enrollment rate for Medicaid recipient cases processed by SSA.
  • We lowered the potential costs to a state’s Medicaid program by nearly $70M in the last fiscal year by providing enhanced, one-on-one coordination of Medicaid and private insurance for over 230 Medicaid members with medically complex conditions.

Come Join Us

ForHealth Consulting will be at the Medicaid Enterprise Systems Conference on August 21-24, 2023, presenting on TPL approaches and the latest trends. We invite you to join us and learn more about how to level up with our best practices so you can better serve your members and save your Medicaid program money and resources.

Learn more about how we can help.

1Medicaid and CHIP Payment and Access Commission at https://www.macpac.gov/subtopic/third-party-liability/