06/24/1991 39680

THIRD PARTY LIABILITY PROGRAM INVESTIGATOR

DEFINITION: This is technical professional work in the investigation and settlement of medical assistance related claims and the recovery of funds legally owed to the Commonwealth.

Employees in this class investigate medical assistance related claims, identified by the Trauma Code Tracking (TCT) system, to identify liable third party resources and to recover funds owed to the Commonwealth. Work involves investigating individual cases, generated by TCT questionnaires completed by medical assistance clients, to identify liable third parties or other resources to recover medical assistance benefits paid as a result of a personal injury situation. Employees independently conduct research to identify and analyze information concerning injuries sustained in accidents and other incidents which typically involve numerous variables and potential liable parties; apply state regulations and insurance coverage provisions; contact attorneys, commercial health care and liability insurers, DPW contracted managed care health plans, medical providers, state and federal agencies, caseworkers, ambulance services, police, and others to determine liability for medical payments or if the medical assistance recipient received remuneration as a result of the personal injury; and determine the feasibility of collection efforts. Work involves contacting attorneys to determine the status of lawsuits resulting from accidents which may result in recipients receiving money, issuing subrogation notices, pursuit and settlement of cases for potential remuneration, and negotiating payment. Work also involves applying Pennsylvania insurance laws to compel insurance companies to pay claims for which they are liable; processing medical assistance claim and gross adjustments; recovering overpayment of medical assistance funds; and coordinating program activities with other agencies, such as the county assistance offices, DPW contracted managed care health care plans, the Office of Inspector General, the Bureau of Motor Vehicles, the Bureau of Workman's Compensation, the Insurance Department, the Social Security Administration, and local and state police agencies, county judiciary and domestic relation offices. Work is performed independently under the general direction of a TPL Program Investigator Supervisor in accordance with established mandates, policies, and procedures and requires discretion and judgment in conducting investigations. Work is reviewed through reports, conferences, and results achieved in meeting established goals and objectives.

EXAMPLES OF WORK: Investigates individual cases generated by TCT questionnaires completed by medical assistance recipients, or by other referrals involving TCT issues, to identify liable third parties or other resources to recover payment for medical assistance program services provided to eligible clients as a result of a personal injury.

Evaluates and analyzes MAMIS generated TCT questionnaires completed by medical assistance recipients involved in accidents to determine the nature of the incident, participants involved, dates, descriptions of medical injuries and treatments provided, sources of medical treatment, applicable insurance coverage, and represented attorneys and possible legal actions.

Researches Pennsylvania insurance laws, specific policy coverage and recipient eligibility provisions to determine if a third party is liable for the payment of medical assistance program services provided to a medical assistance recipient.

Applies, interprets, and cites various laws, regulations, and policies in order to maximize cost recovery efforts in the settlement process of a personal injury related case.

Develops and documents a case for each claim; determines if claims are liable for payment by a third party by identifying insurance coverage of the medical assistance recipient or other involved parties or if the recipient has received remuneration as a result of an accident.

Contacts attorneys, commercial insurance companies, DPW contracted managed care health care plans, medical assistance program service providers, ambulance services, police, caseworkers, and state agencies to determine if another party is liable for payment of medical bills related to the personal injury or if there is pending litigation or a lawsuit settlement or award as a result of the personal injury.

Researches histories of medical assistance recipients and participating parties from MAMIS and TPL automated files and analyzes information to determine feasibility and potential for recovery efforts.

Prepares statements of claim for both medical and cash assistance in cases of the overpayment of benefits.

Processes claim and gross adjustments, makes calculations to determine state and federal shares, monitors status, receives checks and coordinates payment to the Comptroller.

Closes out cases at receipt of applicable third party liability payment, upon determination that no third party liability exists or that payment is not collectable.

Identifies and tracks pending litigation by contacting attorneys to promote the Department's interest in sustaining cases for future reimbursement and to determine the status of lawsuits resulting from personal injury which may result in recipients receiving money; issues subrogation notices; negotiates payment with attorneys as a result of lawsuit awards or settlements under the applicable provisions of Act 105,62 PS 1409, or as a result of Workman's Compensation awards, to encourage the settlement of a case by the recovery of funds legally owed to the Commonwealth.

Prepares and transmits correspondence to a variety of sources, including attorneys, providers, recipients, insurers, and various state and federal agencies to support recovery efforts.

Answers inquiries and provides assistance, instruction, and explanations to medical assistance program service providers, insurers, attorneys, and other interested parties on the various aspects of the Third Party Liability Program.

Contacts police agencies to facilitate the establishment of an order in a criminal case to recover monies from the perpetrator of a crime which resulted in an injury requiring the payment of medical assistance benefits.

Prepares status and statistical reports on pending and completed cases.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of regulations, policies, procedures, and rules relating to the various aspects of identifying legally liable third party resources, state insurance laws, Workman's Compensation laws, and Health Care Financing Administration (HCFA) requirements.

Knowledge of principles relating to health care eligibility criteria, billing and provider agreements relating to Medicare, Blue Shield and Blue Cross, DPW contracted managed care health plans, commercial health care, and liability insurers.

Knowledge of the civil court litigation process pertaining to legal settlements for reimbursement and restitution efforts.

Ability to identify, gather, clarify, and explain information requested by or required from the various health care providers, private insurers, and other involved parties.

Ability to apply methods, techniques, and procedures for investigating and settling claims for reimbursement or repayment as a result of litigation or legal settlement for erroneous medical assistance payments on behalf of recipients of medical assistance program services.

Ability to establish and maintain cooperative working relationships with medical assistance recipients, medical assistance service providers, public and private officials, county assistance staff, domestic relations office staff, attorneys, and associates.

Ability to investigate, assemble pertinent factual information into a concise case file, evaluate the case history and correctly categorize the case file given a set of specific criteria.

Ability to effectively communicate, expressing ideas orally and in writing in order to secure evidence, negotiate with attorneys to sustain a pending lawsuit or to obtain remuneration as a result of a lawsuit settlement.

MINIMUM EXPERIENCE AND TRAINING: Four years of experience in the investigation of Health Care and personal injury records, correspondence and documents used in establishing legal liability, or determining approval of health care and personal injury insurance claims.

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One year of experience as a Third Party Liability Program Technician.

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Any equivalent combination of experience and training.