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

% of Medicaid members in the monthly data match who had new or updated commercial insurance policy information

70.1%May 2022

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Notes on Methodology

Partners
  • United Health Care (UHC)
  • Blue Cross Blue Shield of Vermont (BCBSVT)
  • CIGNA
Story Behind the Curve

This measure is important because maintaining accurate commercial insurance information ensures that Medicaid is the payer of last resort by requiring that other insurance companies be billed as the primary insurance for the services received by the member. The Deficit Reduction Act of 2005 requires insurers to provide State Medicaid Agencies with data files of eligibles and State of Vermont Statute 33 V.S.A. § 1908 supports the requirement that insurers provide data files of their eligibles to the State of Vermont Medicaid Program. 

The Member and Provider Services (MPS) Unit’s Third-Party Liability (TPL) Team completes data matching, which is comparing the data files of insurer eligibles to Medicaid eligibles.  When a member on the insurer file is also a Medicaid eligible; insurance information is added or updated in the Medicaid systems.  This ensures that providers bill claims to the insurer before they are billed to Medicaid.  When claims are received for a Medicaid eligible with other insurance, providers are directed to bill other insurance for the services before billing Medicaid.   The TPL Team currently receives monthly insurer files from United Health Care (UHC) and BCBS of Vermont.  Insurer files are reviewed, and insurance data is manually entered or updated in the Medicaid Systems.

BCBS data match file for November 2021 is showing a substantial increase in the number of members reported monthly due to corrected file match. BCBS found subset of member’s who were not on the report which was corrected on their end. Our monthly file with BCBS should become more steady and trendline will become more stable going forward.


Last updated:  01/19/22

Strategy

It is important to being all insurance companies to the table to identify and cost avoid medicaid payments. In 2022, The TPL Team will be working with CIgna to receive a monthly file so that monthly reporting and trendlines can be captured and reported. In addition, begin outreaching and explore onboarding with MVP and Express Script carriers.

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