Identification & Recovery
According to CMS, more than 60 percent of Medicaid beneficiaries have some sort of managed care coverage and 98 percent of Medicare beneficiaries have access to a Medicare Advantage plan. For the managed care plans that cover these individuals, being able to identify other coverage that is available to them can result in significant recovery of payments that were the legal responsibility of a liable third party. HMS also helps managed care plans to avoid paying claims in the future for members who have other coverage.
Identification
Through legislative mandates such as those defined in the Deficit Reduction Act of 2005, HMS has amassed a database of health plan eligibility provided by over 250 insurance carriers nationwide. This database contains nearly 500 million segments of eligibility from various sources, including:- National and regional insurance carriers
- Blue Cross/Blue Shield plans
- Third Party Administrators
- Pharmacy Benefit Managers
- Long-term Care carriers
- Unions and employers
HMS also has access to coverage information from other government healthcare programs, such as Medicare and TRICARE/Champus.
By matching our government-sponsored clients' paid claims to these eligibility sources, HMS identifies instances where a managed care plan paid for services that were the legal responsibility of another party.
Recovery
Following discovery of TPL, HMS initiates recovery either by billing the liable carrier directly or by providing the correct coverage information to the provider of service.HMS has developed sophisticated methods of revenue recovery, including the following:
- Electronic Billing Capabilities. HMS submits over 80% of subrogation claims electronically via various billing platforms available commercially or developed by HMS.
- Yield Management. HMS monitors the outcome of billings we submit, and follows up when claims are denied inappropriately, underpaid, or not processed.
- Provider Recoupments. Where inappropriate payments are to be recouped from the provider of service, HMS automates the recoupment process while being sensitive to providers' needs and questions.