Identification & Recovery

Given the size and complexity of state Medicaid programs, keeping track of other coverage available to Medicaid beneficiaries and coordinating benefits accordingly is not easy. HMS applies data mining techniques to locate valid third party coverage for beneficiaries whose claims have been paid by Medicaid, and initiates recovery.

Identification

Through legislative mandates such as the Deficit Reduction Act of 2005, HMS has amassed a database of health plan eligibility data provided by over 250 insurance carriers nationwide. This database contains nearly 500 million unique 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

We also have access to coverage information from other government healthcare programs, such as Medicare and TRICARE/Champus.

By matching Medicaid paid claims to these eligibility sources, HMS identifies instances where Medicaid paid for services that were the legal responsibility of another party.

Recovery

After identifying other insurance, 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. Over 80% of Medicaid subrogation claims are submitted electronically over various billing platforms, including customer carrier interfaces that HMS has developed, Emdeon (formerly WebMD Transaction Services), and Companion Technologies (TRICARE claims clearinghouse).
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.
Provider Recoupments. Where inappropriate payments are recouped from the provider of service, HMS uses a variety of tools to streamline the process and minimize the burden on providers. Using Web-enabled technology, dedicated toll-free telephone numbers, and Service Center functionality, we work with providers to answer questions and validate findings. Our services help clients strengthen their relationships with participating providers.