How to Get Paid for Patients with a Third-Party Liability (TPL)
If you’ve been in business for longer than a few months, odds are you just cringed when I mentioned patients with a Third-Party Liability (TPL). TPLs are notoriously difficult to collect payment for and can take months to finalize even when you’ve done everything correctly. The unfortunate reality is that everything must be done correctly and in a specific order to ensure that these claims will pay.
So, what are they? And why do they take so long to process? A TPL is when patients are eligible for more than one insurance policy at the same time. For example, “Patient A” has a FL Blue PPO plan but also has a Florida Medicaid plan. In this case, the FL Blue plan would be the primary payor or “TPL” and Florida Medicaid is the secondary payor or the “payor of last resort”. This means that the TPL plan needs to be billed and completely processed before the secondary payor can be billed for any remaining balance.
The reason these claims can take longer to process has a lot to do with the specific procedures and processing times of each payor involved. In many instances, the provider is billing the TPL as an “out-of-network” provider which can results in longer claims processing times or errors and other clinical paperwork requests. All of which take time and detailed follow-up to determine. However, you can navigate this by following some simple steps to hopefully ensure smooth claims processing in the timeliest manner possible.
Steps for processing TPLs:
Verify Benefits for all INS
You should always verify coverage before treating a patient but in this case it’s important to also understand the coverage limitations of a TPL policy. For instance, we need to know if Speech Therapy is a covered condition and if there are any exclusions or authorizations requirements for the codes we intend to bill.
Obtain Auths for all insurances
If an authorization is required for one or both insurances, you must go through the steps to obtain that authorization or you run the risk or denials due to lack of an authorization. Even if you’re out-of-network, you must get an authorization from the primary TPL. Some secondary payors will not pay claims if they weren’t authorized by the TPL.
Bill primary insurance
Send your claims to the primary insurance first.
Obtain remittance from primary
You must get a remittance from the primary TPL before sending any claims to the secondary payor. You need the evidence of a properly processed claim in order to get the secondary insurance to pay the remaining balance.
Bill secondary ins including reason codes and payment info from primary
Once you have the TPL remittance in hand, you can now bill the secondary payor but be sure to include any “paid amounts” and the “reason codes” from the primary insurance so that the secondary payor knows how to process the claim. For example, in the case of “Patient A” listed above, we’ll assume that an hour of Speech Therapy was done and that FL Blue allowed $85 for the hour of Therapy. However, FL Blue paid $55 and informed us that the remaining balance was the patient’s responsibility. In Florida, the Medicaid rate is $71.44 for an hour of Speech Therapy by an SLP. This means that if done correctly, Medicaid should pay an additional $16.44 for the claim. In all cases, Medicaid payors will only pay up to the Medicaid rates for services, never as high as the allowable amounts from the TPL.
Each secondary payor handles TPL claims differently so be sure to call and do your research on each one so that you’re informed on how to send them a TPL claim. Following up on these claims regularly is critical to ensure that you’re not missing timely filing limits and that you don’t fall behind on payments.
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