Historically, payer plans have lacked adequate visibility into the efficacy of third-party liability (TPL) recovery. We help payers obtain a clear line of sight into recoveries, and we ensure that recoveries are optimized.

There are four basic approaches to carrying out TPL functions in a managed care environment:

  • Enrollees with any other insurance coverage are excluded from enrollment in managed care
  • Enrollees with other insurance coverage are enrolled in managed care and the state retains TPL responsibilities
  • Enrollees with other insurance coverage are enrolled in managed care and TPL responsibilities are delegated to the Managed Care Organization (MCO) with an appropriate adjustment of the MCO capitation payments
  • Enrollees and/or their dependents with commercial managed care coverage are excluded from enrollment in Medicaid MCOs, while TPL for other enrollees with private health insurance or Medicare coverage is delegated to the MCO with the state retaining responsibility only for tort and estate recoveries

State Medicaid programs may contract with MCOs to provide health care to Medicaid beneficiaries, and may delegate responsibility and authority to the MCOs and their selected vendors to perform third party discovery and recovery activities. Allēus can provide these services on behalf of the MCO when authorized by the Medicaid program.