Evidence record
States Face Ongoing Challenges in Meeting Third-Party Liability Requirements for Ensuring That Medicaid Functions as the Payer of Last Resort
- Publication date
- October 2023
- Source record
- Original document linked
Findings
15
Recommendations
8
Overall 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.
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.
Findings (15)
Each finding has a stable link.
- F-223
Difficulties Coordinating Third-Party Liability With Medicare.
- F-217
Difficulties obtaining timely and reliable coverage information from third parties.
- F-216
States continue to experience difficulties obtaining complete, accurate, and up-to-date coverage information from Medicaid enrollees and providers.
- F-218
Difficulties coordinating TPL with out-of-State third parties.
- F-219
Technical issues related to third-party coverage information received and electronic billing of Medicaid claims with third parties.
- F-220
Lack of Federal prompt payment requirements and penalties for third parties that do not cooperate with States’ efforts to meet TPL requirements.
- F-221
Difficulties with third parties that deny Medicaid claims for procedural reasons.
- F-222
Difficulties Coordinating Third-Party Liability With TRICARE.
- F-224
Some States did not have in effect laws addressing all Deficit Reduction Act provisions intended to assist States in meeting their third-party liability responsibilities.
- F-225
Twenty-Seven States Did Not Accurately Report Medicaid Third-Party Liability Amounts.
- F-226
Twenty-Seven States did not report Medicaid TPL amounts on CMS-64.9A according to Federal requirements.
- F-227
Twelve States Did Not Report Third-Party Liability Collection Amounts, Cost Avoidance Amounts, or Both.
- F-228
Twenty-One States Did Not Correctly Report Third-Party Liability Amounts.
- F-229
Limitations in CMS’s Analysis of Third-Party Liability Reporting and a Lack of Communication About Reporting Requirements Likely Contributed to Inaccurate State Reporting of Medicaid Third-Party Liability.
- F-230
Financial and Program Integrity Consequences of Undetected Medicaid Third-Party Liability Reporting Errors.
Recommendations (8)
- R-231
Develop an action plan for helping States more easily identify liable third parties and recover Medicaid payments.
Related finding F-216 - R-232
Work with States to encourage better cooperation from third parties that resist TPL identification and recovery efforts.
Related finding F-220 - R-233
For the four States identified as not fully compliant with the DRA’s TPL provisions: verify compliance and pursue corrective actions for noncompliance.
Related finding F-224 - R-234
Verify whether Virginia has refunded the $1.25 million Federal share of the Medicaid TPL collections underreported during two fiscal quarters and, if not, require refund of any remaining amount.
Related finding F-225 - R-235
Provide guidance to States to assist them with developing processes that improve the reporting of Medicaid TPL amounts on the CMS-64.9A.
Related finding F-226 - R-236
Ensure that States have current instructions on completing the CMS-64.9A.
Related finding F-229 - R-237
Ensure that States correctly report TPL amounts on the CMS-64.9A.
Related finding F-228 - R-238
Remove or disable lines from the CMS-64.9A that States use for reporting TPL amounts (notes on form adjustments).
Related finding F-229