Indiana’s Third-Party Liability (TPL) Disallowance Project supplies Indiana Medicaid providers with Medicare and third-party commercial insurance information to properly bill claims to the primary carrier. Managed by the Indiana Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) through its fiscal agent, Gainwell Technologies, and subcontractor, HMS, the TPL Disallowance Project identifies paid Indiana Medicaid claims for which there is third-party coverage and notifies providers via U.S. mail of the third-party coverage information.
Once notified, providers have 60 days to bill the third-party carrier and respond to HMS. Presumably, the third-party carrier will pay the identified claims and HMS will recoup the overpayment made by Indiana Medicaid. However, if payment is not available from the other insurer, providers must notify HMS within the allotted 60-day period and provide documentation that no third-party carrier coverage was available or the carrier denied the claim in order to avoid an inappropriate recoupment.
A Struggling Effort
While the TPL Disallowance Project identifies claims already paid when third-party coverage is available, Indiana’s TPL Program attempts to identify IHCP members who have third-party resources available before payments are made by IHCP. According to the Department of Health and Human Services Office of Inspector General (OIG), however, the program isn’t working as effectively as it should.
A September 2020 OIG report found that Indiana did not ensure that Medicaid payments were made properly for some claims identified as having third-party coverage. Specifically, Indiana ensured that Medicaid payments were made properly for claims for which the members had been identified as having third-party coverage for only 54 of the 120 sampled claims. For 9 of the 120 claims, Indiana should not have paid some or all of the Medicaid payments totaling $5,082. For the remaining 57 claims, as well as 6 of the 9 overpayments, the OIG found that Indiana; its contractor, DXC Technology (DXC); or DXC’s subcontractor, HMS, did not
- maintain accurate or complete information, or both, to avoid or recover Medicaid payments when there was TPL;
- verify that members had other Medicaid expenditures to which excess payments received from third party carriers could be applied; or
- did not bill the third-party carrier in a timely manner or did not pursue recovery when there was TPL.
Based on those results, the OIG estimated that Indiana made Medicaid overpayments totaling at least $54,965 ($36,573 Federal share) for service dates during the audit period and recommended that the state refund $36,573 to the Federal Government.
What Providers Should Do
Providers can access the HMS’s secure web-based Provider Portal to review claims included in the TPL Disallowance Project. The portal includes access to a complete list of patients, claims, and primary insurance information necessary to file claims with other carriers when a patient has health insurance primary to Medicaid. Providers also can use the HMS Provider Portal to acknowledge or dispute recovery requests and upload documentation.
To set up an account, providers can self-register at: https://hmsportal.hms.com/registration. Accounts can also be established by emailing HMS at hmsppuserverification@hms.com or by calling HMS at 1-855-554-6748. Additionally, providers can contact HMS Provider Relations at 1-877-264-4854 or via fax at (214) 905-2064.
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