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Benefit Recovery COB/TPL
Jan Taylor, Manager Benefit Recovery Section
DHS Health Care [email protected]
651-431-3139
Benefit Recovery Section
Responsible to ensure that MHCP is payer of last resort; all other resources must be used to fullest extent
Partner with financial worker staff in many ways to gain information and fulfill responsibilities
Important that clients understand their responsibilities about TPL
Units within BRS
Health Insurance Unit
Tort Liability Unit
MA Lien and Estate Recovery Unit
Medicare Revenue Enhancement (LTC)See Handout Pg. 1—BRS Contact List
Health Insurance Unit
Maintain the TPL Resource File in MMIS– Reviewing county added TPL records
(including those interfaced from PRISM)– Incoming faxes from medical providers—
updates– Reviewing Possible Insurance Cases for
unknown TPL
See Handout—Attachment A
Health Insurance Unit
Bill health insurers for retro coverage
--Processing TPL payments/denials Review & Approve Cost Effective Health
Insurance policies File updates with data match results
– Child support (daily)– Tricare (annually)– Other insurance carriers (current RFP)
Medicare & LTC Insurance are TPL
Regardless of where the payment of benefits is directed
– LTC insurance must be coded as a policy in MMIS/TPL Resource
– Providers of LTC services must bill and report receipt of payment on the claims submitted to MHCP
Do Not Treat LTC Insurance Proceeds as Income/Assets
If the policy is not specifically “income replacement” it is TPL
If benefits are payable as a result of home care services or NF services = TPL
Client or personal rep must pay the benefits to the nursing home
Coverage Types Expanded
MMIS has new Coverage Types for the expanded benefits of LTC insurance
– 13—Nursing Home Only – 27—Nursing Home + Home Care*– 28—Nursing Home Only (Partnership Qualified)*– 29—Nursing Home + Home Care (Partnership
Qualified)*
*New Coverage Types were Implemented February 2008; See LTCP Bulletin #08-21-08.
Services Covered by Managed Care Organization (MCO)
If SNF or Home Care services are covered by an MCO, LTC insurance benefits are payable to the MCO
The LTC insurance payments must be reported on the claims submitted to the MCO
The MCO is secondary to LTC insurance benefits
New Initiatives for Improved Efficiency
Quality improvement process (Lean/Kaizen) used for three major BRS processes
County staff members participated in a short-term “Focus Group” to review draft products and provide input
Cost Effective Health Insurance
Decision Tree (In Development)
Decision Tree (State Agency Staff)
“Standard Work” Document in Use for BRS Staff
Process Changes Identified
CEHI Form is being revised (Draft)
MMIS Request for “Combo Screen” of data relevant to CE review
Use of Fax for Future Requests and
Workflow Changes
Tort Liability Unit Pursues TPL Related to Accidents/Injuries
--Grant money may be part of BRS Claim
“Leads” to Cases– Client has a duty to report– Attorney for client is looking for medical
expenses paid as related to the injury– Medical Service Questionnaires are
generated– Refer calls/correspondence to BRS
Tort Liability
Types of Tort TPL– Workers’ Compensation (DOLI data match)– Auto no-fault/auto litigated– Homeowners’ Insurance – Medical Malpractice – Product liability (rx drugs, devices, etc.)– Personal Liability– Class Action or Multiple Plaintiff Cases
MSQ Process
“Standard Work” (final)
FAQs Document (See Handout—Att. D)
MMIS Changes
Improve compliance with form completion/return
Reduce turn-around time
Form Revision
Simplify form & use “flash print” or “script” process rather than hard copy forms (pin-feed)
Proposed New MSQProcess
Daily process and direct mail of First/Sec. Notice MSQs
Move parameters on notices up (from 90 days to 60 days to 45 days)
Rely on county staff to apply closing guidelines at Worker Message
MA Lien & Estate Recovery
County agency staff send MA Lien Referral Worksheets and SNT Referrals to BRS
BRS staff file MA property liens when appropriate and monitor SNT clients
County Agency staff file estate claims upon the death of the last surviving spouse
BRS provides technical assistance to county collections staff
Medicare Revenue Enhancement (MREP)
Program to ensure that Medicare benefits are used first for LTC Services
LTC facilities required to submit documentation for review of potential cases
Technical assistance provided to LTC facilities re: Medicare, and other requirements
Deficit Reduction Act (DRA) & LTC Partnerships
MN passed implementing language effective 07/01/06 based on DRA authority given to states – More people will be buying LTC insurance
which may or may not be Partnership qualified
– All LTC insurance has the effect of protecting assets (by virtue of providing the benefit)
Goals
Effective communication with external customers (develop and maintain presence on public and county websites, etc.)
More efficient processes with better results
Continue to review & implement changes