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Manage TPL Recovery

Accounts Receivable Management

Description

The Manage TPL Recovery business process begins by receiving Third-Party Liability (TPL) information from various sources such as external and internal information matches, tips, referrals, attorneys, compliance management incident, Medicaid Fraud Control Unit (MFCU), providers, and insurance companies. The business process: • Identifies the provider or TPL carrier, locates recoverable claims. • Creates the coordination of benefits file. • Creates post-payment recovery files. • Sends notification to other payer or provider from the Manage Provider Communication business process.

Business Process Template

Trigger events
Environment-based
  • Receive third-party liability information from outside sources via the Determine Member Eligibility business process.
  • Receive third-party liability information from internal and external eligibility information matches. State transition-based Trigger Events:
  • Receive claims payment information from Process Claim or Process Encounter business process.
Interaction-based

None published

Results
  • Alert sent to notify third-party liability of recovery request.
  • Alert sent to Manage Accounts Receivable Information business process to monitor for payment.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Receive third-party liability information.
  • 2. Identify the provider or TPL carrier.
  • 3. Locate recoverable claims.
  • 4. Create coordination of benefit files.
  • 5. Create post-payment recovery files.
  • 6. Send alert to notify provider or other payer of recovery request.
  • 7. Conduct follow-up necessary and record activities.
  • 8. Send alert to monitor recoupment activities to Manage Accounts Receivable Information business process.
  • 9. END: Close and archive TPL Recovery case file upon conclusion of activities.
Predecessor processes
Successor processes
Shared data
  • Financial data store including accounts receivable information
  • Member data store including enrollment information
  • Provider data store including provider network and carrier information
  • Health Insurance Marketplace data store
  • Compliance Management data store including compliance incident information
  • Other Agency Information: - Department of Motor Vehicles (DMV) - Veterans Administration (VA) - Indian Health Service - Immigration and Naturalization Service - Medicaid Fraud Control Unit (MFCU)
Constraints

States differ in the rules applied to TPL recoveries. Capabilities related to information matches vary and some States utilize recovery services contractors. The state’s integration of eligibility determination systems also has significant impact on their ability to cost avoid versus cost recover.

Failures
  • Inability to identify third-party payer from received third-party liability information.
  • Identified third-party payer denies liability or otherwise refuses to pay.
Performance measures
  • Time to complete the process = Real Time response = within __ seconds, Batch Response = within __hours
  • Accuracy with which the TPL rules are applied = __%
  • Consistency with which the TPL rules are applied = __%
  • Amount of dollars recovered = ___%
  • Error rate (false recovery demands) = __% or less

Source: CMS MITA 3.0 Business Process Template, Financial Management BPT.pdf, pages 3-5.

Business Capability Model (13 questions)

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

Business Capability Descriptions

Is the process manual or automatic?
  1. LEVEL 1The process consists primarily of manual activity to accomplish tasks. The process is primarily manual utilizing a mix of paper, telephone, facsimile, and some proprietary Electronic Data Interchange (EDI).
  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. The process uses MITA Framework, industry standards, for payer-to-payer Coordination of Benefits (COB) process reducing the burden to providers and optimizing timeliness.
  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.
How does the State Medicaid Agency validate Third Party Liability (TPL) information?
  1. LEVEL 1SMA manually validates Information regarding third-party resources.
  2. LEVEL 2SMA uses electronic information from other payers for information matching and validating of member TPL information.
  3. LEVEL 3MITA interface standards support completely automatic validation of TPL information.
  4. LEVEL 4SMA automates process to the full extent possible across the interstate to validate TPL information.
  5. LEVEL 5SMA automates process to the full extent possible across the nation to validate TPL information.
How integrated is the process?
  1. LEVEL 1There is little coordination between the portions of SMA responsible for recoupments: third party liability, program integrity, and accounting.
  2. LEVEL 2SMA centralizes common processes to achieve economies of scale and increase coordination.
  3. LEVEL 3SMA fully integrates the process within SMA with MITA Framework, industry standards, used for electronic interchanges between agencies and other entities that are sources of TPL information (e.g., COB information is available via the Health Information Exchange (HIE).
  4. LEVEL 4SMA fully integrates the process interstate to the extent possible with information exchange via the regional Health Information Exchange (HIE).
  5. LEVEL 5SMA fully integrates the process nationally to the extent possible with information exchange via the Nationwide Health Information Network (NwHIN).
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 conduct coordination of benefits (COB)?
  1. LEVEL 1SMA primarily conducts TPL recovery via payer-to-provider COB.
  2. LEVEL 2Some TPL recovery is payer-to-provider and the remaining is payer-to-payer COB.
  3. LEVEL 3SMA conducts TPL recovery via payer-to-payer COB. SMA has communications available electronically to members and providers.
  4. LEVEL 4SMA conducts TPL recovery via payer-to-payer COB.
  5. LEVEL 5SMA conducts TPL recovery via payer-to-payer COB.
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 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). The process completes in multiple months.
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements. The process completes in weeks.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. The process completes in multiple in business days.
  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. The process completes within hours.
  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.
  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 and workflow 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 99% 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 rating is at 99% 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 rating is at 99% 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.
  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 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 98% 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 8-15.

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