Third-Party Liability Updates

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As of July 1, 2016, Third-Party Liability changes are in effect. This requires that facilities exhaust all other health insurance sources before submitting a claim to Medicaid (the payer of last resort). WHCA/WiCAL continues to carefully monitor any outcomes from these changes.

Beginning April 1, a trial period began after which claims submitted needed to show that a reasonable effort was made to collect from other payer sources. ForwardHealth did not deny any claims during that period, but notified facilities that they will have their payments denied in the future if they don’t pursue other payment sources that are required to be pursued first. Claims denials began July 1. A box has been added to the payment checklists that will ask whether the facility made every attempt to exhaust all other payment sources.

As a reminded to members, WHCA staff spoke with DHS Audit officials who have confirmed that:

  • Facilities will not be required to receive a written denial, however, facility personnel are asked to document the number they called, the person they spoke with and the reason for the denial.
  • Denial from another source of insurance cannot be based on a lack of prior authorization or the resident being out of network, but the state will honor other claims for other reasons.
  • Facilities do not have to continue securing denials after each billing cycle after they have received an initial denial from alternate insurance sources.
  • If it has been more than 120 days since admission, the claim will be paid.

Please visit our TPL member resources page for more information including a memo from DHS. A recording of our March Financial Affairs webinar focused on this topic is available here.

WHCA would like to hear from members about their experiences with Third-Party Liability changes. Please contact Kate Van Camp (kate@whcawical.org) with any problems you’ve faced or other comments since the July 1 updates.

Posted in Medicaid