Given the complexity of today’s healthcare coverage environment, keeping track of other coverage available to beneficiaries and coordinating benefits accordingly is not easy. HMS applies proven data mining techniques to locate valid other coverage available to program beneficiaries, and can pursue recoveries for claims that were paid inappropriately.
Many types of HMS clients benefit from these services, including:
- Medicaid (and their contracted managed care plans) who must do their due diligence to determine Third Party Liability and pursue recovery
- IV-D agencies wanting to locate the availability of insurance held by the non-custodial parent
- Veterans Affairs Hospitals that want to identify commercial coverage held by their patients
Identification
HMS has amassed a National Eligibility Database of health plan eligibility data provided by over 1,000 insurance carriers nationwide that is updated regularly. Governed by formal Data Use Agreements, this database contains over 1.2 billion unique current and historical segments of eligibility from various sources, including insurance carriers, Third Party Administrators, Pharmacy Benefit Managers, and unions. We also access coverage information from other government healthcare programs, such as Medicare and TRICARE/Champus.
By matching a program’s eligibility files to our National Eligibility Database, HMS identifies instances where program beneficiaries receive health coverage benefits from other sources. Our multipronged, iterative matching process has been independently proven to outperform similar approaches offered by our competitors, and it can be offered in real time.
Recovery
After identifying other coverage for beneficiaries, HMS investigates claims that have been paid erroneously for these individuals and initiates recovery, either by billing the liable carrier directly or by providing the correct coverage information to the provider of service.
HMS’s standard approach to revenue recovery includes the following:
- Electronic Billing Capabilities. Nearly 90% of Medicaid subrogation claims are submitted electronically over various billing platforms, including customized carrier interfaces specially developed by HMS, as well as commercial clearinghouses.
- Yield Management. HMS monitors the outcome of billings we submit, including those that are denied inappropriately, not paid in full, or not processed by the carrier. We follow up with payors to pursue payment and maximize recoveries to our clients.
- Provider Recoupments. When recovering inappropriate payments directly from the provider of service, HMS tools streamline the process and minimize provider burden. Using web-enabled technology and Service Center functionality, we work with providers to answer questions and validate findings. Our services help clients strengthen their relationships with participating providers.
Our case management system is the only one designed specifically to support Medicaid subrogation.
