From Complex to Cash Flow:
Taking the Complexity out of TPL Claims
to Optimize Reimbursement
Webinar Transcript

Kelly Ammons: Good afternoon, everyone. Thank you for joining us today for our webinar. My name is Kelly Ammons, and I am the President-Elect for the Colorado chapter.

I'd like to welcome Cassie Hansen and Justin Myers from Elevate Patient Financial Solutions. They will be discussing third-party coverage and liability.

If you're attending for CPE credits, please remember that you must stay for the full 50 minutes. There will be survey questions throughout the presentation, so be sure to participate. There will also be a feedback survey at the end.

If you have questions during the presentation, please enter them in the chat. I'll monitor them and alert Justin and Cassie so they can address them. This webinar is being recorded. You'll receive the recording within 72 hours, and we will also send out the slide deck afterward.

Division President and COO of Complex Claims Justin Myers: I'll kick things off. Before we begin, I'd like to provide a brief introduction.

I'm the Division President and COO of Elevate. I've been with ElevatePFS since 2008. I'm an attorney based in Texas and have been licensed since 2004, practicing in healthcare since that time. I joined ElevatePFS through an acquisition in 2008.

Cassie, I'll let you share your background as well.

Executive Vice President of Third Party Liability and Workers' Compensation Cassie Hansen: Good afternoon, everyone. I'm Cassie Hansen.

I currently serve as Executive Vice President overseeing TPL operations for ElevatePFS. I've worked in revenue cycle management focused on complex claims for approximately 18 years, and I'm also a licensed attorney. I'm based in Mississippi and practiced law privately before entering the healthcare sector.

Thank you for having us today.

Justin Myers: Thank you all for having us. We've worked in the third-party liability and accident account space for many years, and we're excited to share our experience and knowledge with you.

Today we'll discuss what TPL is, the challenges associated with accident accounts, why hospitals often struggle with these accounts, the fundamentals needed for effective management, TPL program best practices, and options for structuring a TPL program.

TPL stands for Third-Party Liability. When hospitals refer to a TPL account, they're generally talking about coverage associated with an accident.

While automobile accidents are the most common example, we've worked many different types of accident-related claims over the years. We've handled cases involving motor vehicle accidents, slip-and-fall incidents, animal bites, and other situations involving the fault of another party.

In general, a third-party liability account involves injuries caused by someone else's actions or negligence. Accident accounts create several challenges for hospitals.

First, they tend to be slow-paying accounts. First-party coverage often pays relatively quickly, but third-party liability claims usually involve lengthy investigation and settlement processes. This increases and ages accounts receivable.

Second, they're labor intensive. Teams must identify insurance information, work with adjusters, coordinate with attorneys, and investigate accident details. This requires specialized expertise and technology.

Finally, hospitals are often dealing with multiple parties whose interests don't necessarily align with the hospital's interests. Attorneys, patients, and insurance companies are generally focused on protecting their own interests.

Cassie Hansen: Because of these challenges, TPL is often considered part of complex claims management.

Many hospitals ask why they should dedicate a separate process to accident accounts, especially when they represent a relatively small percentage of total inventory. The answer is opportunity.

Although these accounts may represent a small portion of accounts receivable, they often produce some of the highest recoveries. Collections from TPL claims can exceed 40 to 50 percent of what is typically recovered from many traditional health insurance or self-pay accounts.

TPL accounts may also be among the few claim types where hospitals can potentially recover full charges rather than contracted reimbursement rates.

Compliance is another important consideration. Federal and state Medicaid regulations often require providers to exercise due diligence in billing primary TPL coverage before Medicare or Medicaid.

Failure to bill properly can result in denials, increased accounts receivable, and additional rework for staff.

A structured TPL program helps identify accident accounts, reduce denials, improve reimbursement, increase cash collections, and prevent missed revenue opportunities.

Accident-related accounts often involve multiple types of coverage.

Medical Payments Coverage, commonly called Med Pay, and Personal Injury Protection, or PIP, are considered first-party coverages.

These coverages provide quick financial assistance for injured patients and may cover medical expenses, lost wages, and household services.

Med Pay is generally optional coverage and often has low policy limits, commonly between $1,000 and $5,000. Because benefits can be exhausted quickly, early identification and billing are critical.

PIP differs slightly because some states require it. Utah is an example of a mandatory PIP state. PIP is generally treated as primary coverage.

Patients may also have access to liability coverage if another party caused the accident. Liability claims depend on fault and are intended to compensate injured parties for damages. Minimum coverage limits vary by state but are commonly between $25,000 and $50,000.

Unfortunately, severe injuries often produce medical costs that exceed available policy limits. In some cases, the at-fault driver may have no insurance at all.

Patients may also carry uninsured or underinsured motorist coverage on their own policies. This coverage can provide additional compensation when the at-fault party lacks adequate insurance.

States generally operate under either fault-based or no-fault insurance systems.

In fault states, responsibility is assigned to the party who caused the accident. Disputes over fault and damages can result in litigation, which often prolongs settlements.

Patients may have a year or more before they're required to file a lawsuit, and some states allow several years before legal action must be initiated. Once litigation begins, discovery and motion practice can further delay resolution.

No-fault states attempt to reduce litigation by requiring each party's insurance to cover its own medical expenses regardless of fault.

Because PIP coverage plays a larger role in those states, policy limits are often higher.

Another important tool available in many states is the hospital lien.

Hospital lien laws vary by state, but most states permit hospitals to assert a statutory right against settlement proceeds related to injuries they treated.

Hospital liens help protect providers by preventing situations where patients receive settlement funds but do not pay their medical bills.

It's important to understand what hospital liens are and what they are not.

Hospital liens apply only to settlements, judgments, or compromises. They do not attach to a patient's personal property, garnish wages, or prevent the sale of property.

A hospital lien is simply one tool that allows providers to protect their right to reimbursement from settlement proceeds.

Many patients are understandably concerned by the word "lien," so education is an important part of the process.

Cassie Hansen: To maximize revenue recovery, hospitals need a strong TPL process.

Organizations should thoroughly investigate why a patient received treatment, whether an accident occurred, and what coverage may be available. Identified payers should be billed as quickly as possible, particularly first-party coverages with limited benefits.

When appropriate, liens should be filed and maintained according to state requirements.

Hospitals cannot simply bill and wait. Successful programs require consistent follow-up with insurance adjusters, attorneys, patients, and other stakeholders. Payments and denials should be reviewed carefully to ensure proper reimbursement and identify appeal opportunities.

Organizations should also quickly identify situations where settlements were paid without appropriately recognizing a valid hospital lien and take timely action when necessary.

Patient education remains critical throughout the process because accident claims and liens can be confusing and intimidating.

Justin Myers: When we begin working with a new client, discovery is often the biggest opportunity for improvement.

Many organizations fail to identify all accident-related accounts or available coverages. Cassie, would you agree that discovery is where we most often see benefits? Absolutely. If accident-related accounts aren't identified, they become missed revenue opportunities.

Organizations need multiple methods for reviewing inventory, identifying accident-related treatment, monitoring trends, and evaluating whether process changes have reduced identification rates.

Given turnover in registration and patient access departments, ongoing education and training are essential.

Patient cooperation is a vital component of any TPL process.

Today's patients are often less responsive to traditional phone calls and may be skeptical of unknown callers.

Research consistently shows that many patients prefer communication through text messaging and email. They also respond better when organizations offer multiple communication channels.

An omni-channel approach improves patient responsiveness, helps identify coverage information more quickly, and increases the likelihood of successful claim management.

Patients are also more likely to engage when communications come from a trusted and recognizable brand.

Increased engagement ultimately leads to better coverage identification, faster claims processing, increased collections, and improved cash flow.

Compliance is a critical component of any TPL process. Organizations must track all available coverages, meet payer-specific deadlines, maintain proper billing sequences, and comply with state lien requirements.

Because multiple payers may be involved, staff members need expertise in determining payment priority and managing overpayments, refunds, and rebilling activities appropriately.

Hospitals evaluating their TPL processes often consider whether to manage them internally or outsource them.

Most traditional revenue cycle systems are not specifically designed for TPL claims management. Specialized technology can improve tracking, compliance, reporting, and efficiency.

Outsourcing may also allow organizations to redirect internal staff toward other priorities.

TPL work requires knowledge of insurance coordination, state lien laws, case law, attorney negotiations, appeals, collections, and compliance. A specialized partner can often provide expertise that may not exist internally.

Many outsourced TPL arrangements operate on a contingency basis, meaning fees are tied directly to recoveries rather than requiring a significant up-front investment.

Organizations should also carefully evaluate security standards and ensure any partner maintains robust security programs and compliance controls.

Is it appropriate to bill the patient while waiting for a settlement? Generally, yes, provided you're mindful of any applicable rules regarding other available coverage.

If you're waiting for a patient to settle a claim with an insurance carrier, you can typically continue billing the patient. Nothing generally requires providers to stop billing.

Even in states without hospital lien laws, providers still have collection rights and options beyond liens.

However, if Medicare, Medicaid, or other health insurance coverage is involved, you need to ensure you're following payer-specific requirements before billing the patient directly.

If the account is self-pay and your system allows it, billing the patient can serve as a useful reminder that they remain responsible for the balance.

Justin Myers: I would add one caution. Be careful with self-pay discounts. If a discounted balance appears on a patient statement and later must be reversed, that can create confusion and difficult conversations.

Cassie Hansen: That's a good point. You also need to make sure these accounts don't inappropriately move into bad debt or collections while a lien strategy is still being pursued.

Follow-Up Question: Doesn't Billing the Patient Seem Unfair When Settlements Take Years? That's why these accounts need careful monitoring.

Organizations need to stay aware of statutory deadlines and compliance requirements while also recognizing that many TPL recoveries are pursued through settlement proceeds rather than directly from patients.

There are often ways to manage these situations without creating unnecessary burdens for patients.

Justin Myers: If there are no additional questions, we'll go ahead and wrap up. We appreciate everyone attending today. Thank you for listening. We'll circulate the PowerPoint presentation over the next few days. If you have any questions afterward, please feel free to reach out.

Cassie Hansen:
Thank you, everyone. We appreciate your time this afternoon. Have a great day.