States Face Ongoing Challenges in Meeting Third-Party Liability Requirements for Ensuring That Medicaid Functions as the Payer of Last Resort
Learn how the AI-generated research projects were createdOverall Conclusion
OIG concludes that States continue to face persistent and wide-ranging challenges in meeting third-party liability requirements for Medicaid, even after the Deficit Reduction Act provisions and CMS guidance. The report notes substantial reporting errors by numerous States, limited CMS analysis on TPL reporting detail, and ongoing resistance by some third parties. CMS concurred with the recommendations and outlined steps to provide updated guidance and actions to address these challenges.
Source Document
Audit Scope
This audit examined the States and the District of Columbia collectively referred to as “States” for their implementation of Medicaid third-party liability (TPL) requirements, including identification of enrollees’ third-party coverage, determination of TPL for services, cost avoidance, and cost recovery across the Medicaid program. It evaluated actions taken by all 50 States and the District of Columbia (DC) to identify liable third parties and recover Medicaid payments, and assessed whether TPL amounts were reported on the CMS-64 and CMS-64.9A according to Federal requirements. The audit covered data and reporting for Federal FYs 2019 and 2020 (October 1, 2018, through September 30, 2020) and included cross-cutting considerations involving out-of-state third parties, TRICARE, and Medicare coordination. The audit drew on State questionnaires, CMS-64 submissions, and related guidance and statutory provisions such as the Deficit Reduction Act (DRA) provisions amended in 2005.
Key Findings Summary
Difficulties Coordinating Third-Party Liability With Medicare.
Difficulties coordinating TPL with out-of-State third parties.
Twenty-Seven States did not report Medicaid TPL amounts on CMS-64.9A according to Federal requirements.
View the Findings tab to see all 15 findings
AI-Assisted
AI Scope Summary
Assess the ongoing challenges States face in meeting Medicaid TPL requirements as payer of last resort, actions States have taken to address those challenges, and the accuracy of States’ CMS-64 reporting of TPL amounts for FYs 2019–2020.
AI-Generated Insight
This report underscores enduring gaps in data quality, inter-agency coordination, and stakeholder cooperation that hinder Medicaid’s operation as payer of last resort. It highlights a need for stronger federal action, standardized data exchanges, clearer reporting instructions, and enforcement mechanisms to ensure that third parties contribute timely and accurate information and reimbursements, ultimately protecting federal and state Medicaid funds.