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Manage Estate Recovery

Accounts Receivable Management

Description

Manage Estate Recovery is a business process that requires States to recover certain Medicaid benefits correctly paid on behalf of an individual, by filing liens against a deceased member’s or deceased spouse’s estate to recover the costs of Medicaid benefits correctly paid during the time the member was eligible for Medicaid. Estate recovery usually applies to permanently institutionalized individuals such as persons in a nursing facility, Intermediate Care Facility for Persons with Mental Retardation (ICF/MR), or other medical institution. The Manage Estate Recovery business process begins by receiving estate recovery information from multiple sources (e.g., vital statistics and Social Security Administration (SSA) date of death matches, probate petition notices, tips from caseworkers, and reports of death from nursing homes). It generates correspondence (e.g., demand of notice to probate court via Send Outbound Transaction, to member’s personal representative, generating notice of intent to file claim and exemption questionnaire) via the Manage Applicant and Member Communication business process. In addition, the business process: • Opens a formal estate recovery case based on estate ownership and value of property. • Determines the value of the estate lien. • Files a petition for a lien. • Files an estate claim of lien. • Conducts case follow-up. • Sends an alert to Manage Accounts Receivable Information business process, releasing the estate lien when recovery is complete. • Sends an alert to Manage Member Information business process, updating Member data store. NOTE: Do not confuse this with settlements that are recoveries for certain Medicaid benefits correctly paid on behalf of an individual because of a legal ruling or award involving accidents.

Business Process Template

Trigger events
Environment-based

None published

Interaction-based
  • Receive member or provider death certificates. * Many States have Medicaid Estate Recovery Plans used to recover an equitable amount of the state and federal shares of the cost paid for the member from the estates of members of medical assistance.
Results
  • Estate recovery case file closed upon Receive maximum possible payment.
  • Tracking information as needed for measuring performance and business
  • activity monitoring.
Business process steps
  • 10. START: Receive estate recovery referral information via several different sources (e.g., vital statistics and Social Security Administration (SSA) date of death match, probate petition notices, eligibility caseworker, and nursing homes).
  • 11. Send demand notice information to member correspondence (e.g., onto probate court).
  • 12. Send alert to notify deceased representative to complete estate recovery questionnaire.
  • 13. Open estate recovery case.
  • 14. Determine value of estate lien by analyzing all Medicaid claims from age 55 forward (e.g., all paid claims equals lien amount).
  • 15. If applicable, member may file an undue hardship waiver based on state regulations. If the State Medicaid Agency (SMA) grants hardship, staff defers or closes the case.
  • 16. Generate estate recovery proceedings information (e.g., lien petition, notice of pendency of action) and send via Send Outbound Transaction.
  • 17. Upon court approval, file estate claim of lien.
  • 18. Case follow-up occurs (every 30 to 90 days).
  • 19. Send alert to monitor recovery activities to Manage Accounts Receivable Information business process.
  • 20. If applicable, send alert to Manage Member Information business process, updating Member data store.
  • 21. END: Closed and archive estate recovery case file upon conclusion of activities.
Predecessor processes
  • Receive Inbound Transaction
Successor processes
Shared data
  • Financial data store including accounts receivable information
  • Member data store including demographics
  • Claims data store including payment information
  • Vital Statistic records
  • SSA records
  • Centers for Medicare & Medicaid Services (CMS) Medicare/Medicaid Dual Eligibility reporting
  • Health Insurance Marketplace data store
  • Judicial records
Constraints

The Manage Estate Recovery business process will be in accordance with state specific policy.

Failures
  • The SMA or member’s representative is unable to meet filing timelines.
Performance measures
  • Time to complete the process = e.g., ___ months, ___ weeks or ___ days
  • Accuracy with which rules are applied = __%
  • Consistency with which rules are applied = __%
  • Error rate = __% or less
  • Amount of dollars recovered = ___%

Source: CMS MITA 3.0 Business Process Template, Financial Management BPT.pdf, pages 5-7.

Business Capability Model (12 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

Is the process primarily manual or automatic?
  1. LEVEL 1The process consists primarily of manual paper-based activity to accomplish tasks.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks.
  3. LEVEL 3SMA automates process to the full extent possible within the intrastate.
  4. LEVEL 4SMA automates process to the full extent possible across the interstate.
  5. LEVEL 5SMA automates process to the full extent possible across the nation.
What is the media of communication with stakeholders involved in the recovery?
  1. LEVEL 1SMA communicates with stakeholders and members' personal representatives via telephone, in person, facsimile, e-mail and mail.
  2. LEVEL 2Communication to stakeholders and members personal representatives is a mix of telephone, facsimile, and mail, plus the use of e-mail and electronic interchange for exchange of larger or standardized sets of information.
  3. LEVEL 3SMA communicates with stakeholders via primarily electronic media; paper communications are the exception.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and national standards for communications across the interstate.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and national standards for communication across the nation.
How integrated is the process?
  1. LEVEL 1SMA has little coordination with other entities that are information sources. Data is not standardized and is often paper based.
  2. LEVEL 2Agencies are standardizing information to increase coordination and consistency. SMA encourages other stakeholders, including families, attorneys, funeral homes, and others, to use standard information elements. This improves the ability to complete recovery and allows application-to-application updates (e.g., automatic updates of the Member data store and Payment data store).
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA fully integrates the process to the extent possible across the interstate.
  5. LEVEL 5SMA fully integrates the process to the extent possible across the nation.
Does the State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2SMA applies a mix of HIPAA and state-specific standards.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for clinical and interstate information exchange.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national exchange of information.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
  2. LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
  3. LEVEL 3SMA collaborates with other intrastate agencies and entities to adopt national standards, and to develop and share reusable business services.
  4. LEVEL 4SMA collaborates with other interstate agencies and entities to adopt national standards, and to develop and share reusable processes including clinical information.
  5. LEVEL 5SMA collaborates with agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.

Business Capability Quality: Timeliness of Process

How timely is the end-to-end process?
  1. LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2.
  4. LEVEL 4Information is available in near real time. Processes that use clinical information result in immediate action, response, and results. SMA has interstate interoperability, which further improves timeliness over Level 3.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. Most processes execute at the point of service. Results are almost immediate.

Business Capability Quality: Data Access and Accuracy

How accurate is the information in the process?
  1. LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making. Necessary records at the county and local level are difficult to find and are often not available.
  2. LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
  3. LEVEL 3Automation of information collection increases the reliability of SMA's internal information. External sources of information use MITA Framework and industry standards for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy is 90% or higher.
  4. LEVEL 4Automation of information collection increases the reliability of SMA's internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange with interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy is 90% or higher.
  5. LEVEL 5SMA adopts MITA Framework and industry standards for information exchange with national agencies. Decision-making is automatic using national standardized business rules definitions. Accuracy is 90% or higher.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
  3. LEVEL 3SMA obtains information easily and exchanges with intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is greater than Level 2.
  4. LEVEL 4SMA obtains information easily and exchanges with interstate agencies and entities. Accessibility is greater than Level 3.
  5. LEVEL 5SMA obtains information easily and exchanges with national agencies and entities. Accessibility is greater than Level 4.

Business Capability Quality: Cost Effectiveness

What is the cost of the process compared to the benefits of its results?
  1. LEVEL 1High relative cost due to low number of automatic, standardized tasks. High cost of process needed to support and meet recoupment goals.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, and other nationally recognized standards for interstate information exchange. SMA increases cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.

Business Capability Quality: Effort to Perform; Efficiency

How efficient is the process?
  1. LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving efficiency to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

How accurate are the results of the process?
  1. LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 99% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 99% or higher.

Business Capability Quality: Utility or Value to Stakeholders

Does the business process satisfy stakeholders?
  1. LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Financial Management BCM.pdf, pages 15-21.

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