Innovations in Third Party Liability (TPL) Solutions

Date: March 26, 2018||   0  Comments

Deb Grier, VP Enterprise Product Management, HMS sat down with Healthcare IT Connect’s Rob Waters to discuss innovations in Third Party Liability (TPL) solutions and how the evolution towards real-time eligibility determination is enabling states to move towards ‘cost avoidance’ based strategies and away from ‘pay and chase’.

Rob Waters: Third Party Liability represents one of the largest cost-savings opportunities for states to control costs and manage budgets, what should states be thinking about when they are examining the opportunity to evolve TPL to ‘Cost Avoidance’ and away from ‘Pay & Chase’?

DG: Emphasizing robust cost avoidance strategies will deliver improved financial results for states.  Back end recovery efforts are impeded as insurers impose more network and prior authorization requirements, which can be successfully managed on the front end. States need to be ready to adopt these strategies and embed them in their eligibility, financial, and claims management processes. Additionally, states must educate their partners and stakeholders on how these changes will affect them, and why they are important.  HMS can offer support to states in developing financial models that will demonstrate the value of cost avoidance and support funding requests and approaches.

While implementing front end cost avoidance strategies is essential, post-payment processes will still be necessary. Medicaid members’ circumstances change often; and the data discontinuities that occur between reporting changes, eligibility decisions, and claims submission can result in  primary payment by Medicaid when another party may be liable.

Additionally, federal guidelines still require states to pay up front for certain services and recover on the back end; and states are at varying readiness levels to adopt specific cost-avoidance strategies. For all these reasons, when looking to bolster cost savings opportunities, we recommend that states consider all transactional points along the healthcare continuum, from enrollment to post claims submission, that will be best served by the insertion of third party insurance identification and verification before a claim is paid by Medicaid. 

RW: What are some of the innovations in TPL that are enabling states to move to ‘real time’ coordination of benefits as part for the eligibility determination process?

A Medicaid member’s access to third party insurance is dynamic, which creates the need to inject TPL faster, more frequently and at more instances than have been historically considered.  While capturing a continually updated TPL status for all Medicaid members remains vital, HMS is focusing on innovations that bring forth TPL at the point of enrollment, point of prior authorization reviews and point of provider service and billing.  TPL data, while available at those junctures today, is often accessed manually.   HMS’s Enhanced Cost Avoidance suite of services removes the labor-intensive – and oftentimes overlooked – burden of this activity to support effective operations and ensure cost savings are maximized.

RW: How do these innovations align with the modular modernization of MMIS?

DG: HMS designed the technology platform that powers our enhanced cost avoidance suite of services with a decoupled strategy at its core. Our components are modular and flexible, providing services through well-defined API’s. This structure fosters reuse across multiple states and the opportunity for states to mix and match elements of our solution with their existing or planned systems. The platform aligns today with the MITA Modularity standard, with components that are built following a MicroServices approach that can be rolled-up to provide functionality for one or more business processes as defined in MITA business process model. In addition, the platform makes use of a business rules engine, thereby externalizing business rules from programming logic.

RW: What are the procurement options and funding mechanisms available for states to modernize their TPL systems (technology, services, re-use)?

DG:As the MMIS transforms to the Medicaid Enterprise System (MES), Medicaid agencies are faced with a decision on how to treat their TPL functions. With this shift in focus to system modularity, preserving cost containment functions is critical. A complete TPL solution is made up of a combination of data driven deliverables (such as cost avoidance and recoveries) and process driven services (such as subrogation recovery, premium assistance programs, and post payment recovery).  When preparing TPL procurements we recommend the following considerations:

• Understand your state’s TPL needs

• Consider your staffing constraints

• Ensure TPL staff have input on procurements

• Avoid forcing artificial partnerships

• Maintain continuity of recoveries and focus on the best results for all stakeholders

Our recommendation is to position TPL as a standalone procurement, either as its own module or as a service driven procurement, while creating greater interoperability with the core MES through the use of technology that facilitates information and data sharing. Regardless of the approach taken to procure and position TPL, our technology and services have been developed to integrate and exchange data seamlessly with other functions and modules.

Join Deb Grier on: Thursday, April 5 • 4:00pm – 5:00pm Track 4: Evolving Third Party Liability (TPL) towards ‘Cost Avoidance’ and beyond ‘Pay & Chase’, exploring state modernization and procurement models . | . 2018 Healthcare IT Connect Summit

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