Home HIPP Estate Recovery Trauma Recovery Void Request Insurance Adjustment Provider Recoupment Reports Recoupment Guidelines Feedback
Home HIPP Estate Recovery Trauma Recovery Void Request Insurance Adjustment Provider Recoupment Reports Recoupment Guidelines Feedback |
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Dealing With the Trauma Recovery Unit The
Recovery Process
The Recovery Unit (RU) is responsible for the recovery of Medicaid
funds from third parties. HMS currently
contracts with the BMS - DHHR for some of the following key functions of
the unit: Processing
of Accident/Injury Information:
Medicaid customers are bound by contract to assign their rights to
payment for medical care to DHHR.
They are also required to provide DHHR with information that may
assist in the identification of a liable third party. This information may include
attorney contact or insurance information. The RU will then notify those
involved of DHHR’s interest. Upon
contact by an attorney, the RU will establish the customer's Medicaid
eligibility status at the time of the accident, determine whether the
Medicaid program incurred any medical expenses as a result of the accident
or injury and generate a complete medical history of Medicaid claims filed
on behalf of the customer.
This information is available to attorneys who submit a written
request along with a signed release from the customer granting the
attorney access to their medical records. Attorneys should follow five
steps in attempting to determine if their customer was eligible for
Medicaid. ---
Ask
the customer: customers may not tell you unless you ask them ---
Investigate who paid for medical services ---
Contact the RU at 304-342-1604 or via fax at 304-342-1605 --- Email: Rick Levock: rlevock@hms.com ---
Mail
a notice of representation to: 405 Capitol Street, Suite 503, Charleston,
WV 25314
The
RU also conducts a series of mailings to customers for whom Medicaid has
paid claims that have diagnosis codes consistent with trauma-related
accidents. It also routinely conducts data matches with the Division of
Highways and Workers’ Compensation Bureau to identify potential
cases. Determining
Medicaid's Interest Once
the customer’s eligibility has been determined, RU staff will review
Medicaid paid claims reports for claims related to the accident. Customers
sometime receive services about the time of the accident that are not
related to it. Medical
services not related to the accident are excluded from the amount of
Medicaid's interest. Because
Medicaid reimburses inpatient stays based on the Diagnosis Related
Grouping (DRG) system and not on charges submitted, there is usually a
disparity between the amount actually paid by Medicaid and the amount
billed by the provider of service.
In most cases, Medicaid pays less than the amount of the submitted
charges. What happens to the
difference? Contractually,
the provider must accept Medicaid's payment as payment in full and cannot
balance bill the customer for the difference. In
seeking reimbursement, Medicaid can only legally claim repayments up to
the amount that it has expended.
This is another good reason to contact the RU. Once a provider has
submitted claims for adjudication, the provider must accept Medicaid's
payment.
By requesting a detailed list of
the claims paid by Medicaid, you can ensure that your customer is not
paying a claim twice or at a higher rate. Settling
a Case with Medicaid After
you settle your case with the third party, you must pay all the
outstanding creditors and lien holders. In Medicaid's case, you may
forward a check to the RU at the address previously given. In the event of less than full
recovery, the recipient and DHHR shall agree as to the amount to be paid
to the department for its claim.
Reductions may be granted if there are insufficient funds from the
settlement to pay the attorney for fees and expenses. If this situation applies, you can
forward a request for reduction to the RU. Each request must contain
the following: 1.
Amount
and date of the settlement 2.
List of all creditors and amount of their claim 3.
Itemized list of attorney's fees and expenses 4.
Documentation of any reductions from other creditors and/or attorney 5.
Documented reason for requested reduction
Upon receipt the RU will process your request and respond within
five business days.
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