Services

Quick Fact

 

The work of our third-party liability team has resulted in $2.7 billion in cost avoidance and $60 million in cost recovery for the Massachusetts Medicaid program.

Where we’ll be next

Medicaid Enterprise Systems Conference (MESC)

August 18-21 — Denver, CO

This conference brings together thought leaders from the public and private sectors to share ideas and information related the Medicaid systems and initiatives.

We will be speaking and exhibiting at this event; please visit us at Booth 65. We hope to see you there!

Third-Party Liability

Commonwealth Medicine’s financing consultants are experts in maximizing federal reimbursement for Medicaid claims — and generating significant savings for states. Offering a full range of third-party liability services, our Center for Health Care Financing works to ensure that states remain the payer of last resort.

Benefit identification

By identifying liable third parties, our team helps state Medicaid programs avoid paying for services that should be covered by Medicare or a commercial health insurance company. We take multiple approaches, including the following:

  • Finding “dual eligible” Medicaid members — those who are eligible for, or already have, both Medicare and Medicaid coverage. This ensures that state Medicaid programs remain the payer of last resort.
  • Seeking potential private insurance coverage. This increases the number of Medicaid members with commercial health insurance coverage.

In Massachusetts, our team has identified more than 233,000 Medicaid members who also have Medicare and more than 132,000 with commercial insurance.

Benefit coordination

Our benefit coordinators shift more of the financial burden of caring for medically complex, high-cost Medicaid members onto commercial insurance carriers — and away from Medicaid.

In Massachusetts, Commonwealth Medicine’s Enhanced Coordination of Benefits Program coordinates commercial health insurance for this population — avoiding more than $40 million in costs annually for the state’s Medicaid program, MassHealth. We offer the following: 

  • Quick, efficient determinations of whether a patient has access to commercial insurance
  • Maximization of members’ coverage through negotiation with private insurers
  • Personal service to help MassHealth members navigate their benefits and enroll in public assistance programs when eligible

Claims coordination

Our claims coordination team analyzes the adjudication of claims involving commercial insurers and Medicare. Our team produces a wide range of results:

  • Avoids costs by reviewing claims and repricing suspended claims
  • Performs quality control
  • Resolves claims escalation issues
  • Develops procedures for internal staff, customer service, and providers
  • Conducts provider trainings

Casualty and estate recovery

Our casualty recovery team recoups Medicaid dollars from liable parties for injuries due to accidents and trauma. We also recover monies from probated estates through our estate recovery program.

When other third-party liability resources are available and liability has been established, we identify and take back money that has been inappropriately paid for related medical services.

We routinely recover Medicaid funds from third parties such as these:

  • Probated estates
  • Worker’s compensation insurers
  • Automobile liability insurers
  • Medical malpractice insurance
  • General liability

Recovering the cost of medical benefits paid to Medicaid members, whether through our casualty or estate recovery units, helps preserve Medicaid’s status as payer of last resort.