Member and Provider Services Unit: Casualty Recovery and Third Party Liability Teams

What We Do

The Casualty Recovery Team works to coordinate benefit and collection practices with providers, members, and other insurance companies to ensure that Medicaid is the payer of last resort. The team is responsible for Medicare Part D casework including claims processing assistance, coverage verification, and issue resolution.

The Third Party Liability Team (TPL) works diligently to recover funds from third parties where Medicaid should not have been solely responsible. Those efforts include estate recovery, absent parent medical support recovery, casualty recovery, patient liability recovery, Medicare recovery, Medicare prescription recovery, special needs recovery, and trust recovery. The team has been able to increase TPL cost avoidance dollars, a direct result of ensuring that correct TPL insurance information is in the payment systems and being used appropriately.

Please note that in the Fall of 2020 these Teams (formerly known as the Coordination of Benefits (COB) Unit) and the Provider Member Relations (PMR) Unit merged and became the Member Provider Services (MPS) Unit.  They are displayed separately in this scorecard due to their different lines of work.

Who We Serve

The Casualty Recovery and TPL Teams work with providers, beneficiaries, probate courts, attorneys, estate executors, health insurers, liability insurance companies, employers, third party administrators (tpa) and Medicare A, B, C & D plans to ensure that Medicaid is the payer of last resort and that all possible types of recovery are pursued as required by federal law.   

How We Impact

The TPL Team recovers monies that Medicaid has paid as the primary insurer in error, that Medicaid has paid for the care of a beneficiary 55 years of age of older, who received long term care services or that Medicaid has paid for care for a beneficiary with another liable third party.  The collections from the recovery processes are utilized to offset program costs in the yearly Medicaid budget. 

The Casualty Recovery Team assists Medicare beneficiaries with state health/pharmacy assistance obtain their prescription medications at the pharmacy, eligibility for pharmacy assistance, premium assistance, Low Income Subsidy (LIS), Medicare buy-in, and Medicare Open Enrollment.   The assistance given by this team saves beneficiaries monies and allows them to access necessary pharmacy medications at a reasonable cost, while at the same time it saves the State of Vermont millions.  Ensuring that beneficiaries are receiving all of the federal programs (Medicare Buy-in, LIS PART D Coverage) for which they are eligible, means the State of Vermont will not be responsible for the costs of the services/items in the Medicaid budget. 

The updates done to systems to ensure correct claims processing properly, prevents Medicaid from being the primary payer in error, saving the program hundreds of millions of dollars annually.

Action Plan

SFY22 priorities are to:

  • Develop a better understanding of Medicaid member needs, and our response to their needs for information, by working with Maximus to understand the questions/issues/cases the Customer Support Center receives most frequently.
  • Engage with providers to promote participation with the Vermont Medicaid program.
  • Improve automation of the data-matching process to ensure Medicaid is the payer of last resort and cost avoiding when possible.
  • Transition all hard copies files for Estates and Casualty to an online platform so files are easy to access and efficiency improved.
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