When individuals are hospitalized and incur medical charges as a result of injuries sustained in accidents that were not job related, these incidents create third party recovery rights through liens.
Third Party Liability Claims in California
In some cases, contracts and capitation agreements can allow healthcare providers to pursue third parties to obtain reimbursement for full charges. However, third party medical billing can be confusing and any errors made during this process can be difficult to correct. If problems occur, you could be liable because some medical providers find it to be easier to resolve third party medical billing problems by pursuing the patients.
Below you will find helpful information from the Centers for Medicare & Medicaid Services (CMS) website. CMS is a branch of the U.S. Department of Health and Human Services. This federal agency administers all state Medicare programs and monitors all state Medicaid programs.
Third Party Liability - TPL
Third party liability (TPL) refers to the legal obligation of individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a State plan.
Coordination of Benefits - COB
A process referred to as the coordination of benefits (COB) occurs when determining Medicaid benefits after a recipient has qualified for coverage through an individual, entity, insurance, or program that is liable to pay for health care services.
The Medicaid program is intended to be the payer of last resort. All other available third party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid.
Who is Liable to Pay for Services?
Examples of third parties which may be liable to pay for services include self-insured plans, group health plans, managed care organizations, Medicare, court-ordered health coverage, settlements from a liability insurer, workers' compensation, long-term care insurance, and other State and Federal programs.
Individuals who are eligible for Medicaid assign their rights to third party payments to the state Medicaid agency. States are required to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services available under the state plan.