Problem

• Medical office staff who process claims of Medicaid beneficiaries need to understand and apply the rules and requirements related to third-party liability in Medicaid. 

Solution

• Having a solid knowledge of these rules, regulations, and steps increases reimbursement opportunities, improves financial performance of Medicaid programs and providers, ensures compliance with program requirements, and ultimately improves access to health services for those in need.

Approach

• The client for this concept project is a medical office that wants to improve recovery rates from their Medicaid beneficiaries who also have third-party insurance coverage. They recognize that it is in the best interest of their patient, their office, and Medicaid to consistently apply those rules and regulations.  Patients will receive the services they need, offices will safeguard their budgets, and Medicaid will stay solvent and continue providing services to those in need.

• I started my process by researching available sources from the Texas Department of Health and Human Services. I organized the learning experience in three parts: What is Third-Party Liability, Rules and Responsibilities, and Processes.

• This e-Learning module demonstrates the steps to determine third-party insurance elegibility, recovery methods, the rights and responsibilities of patients and stakeholders, how to identify third-party liability sources, and a quick scenario to practice and apply learned information.