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Navigating the Complexity of Third-Party Liability

It's interesting to think that Medicaid third-party liability (TPL) got its start in the ’30s — and how its importance increased as Medicaid enrollees gained access to other coverage options. Gainwell Technologies hasn’t been focused on this area for quite that long, but we’re close, having supported health and human services programs for more than 50 years.

States are, understandably, interested in the savings they can achieve by ensuring they are the payer of last resort. For some perspective, a study from the U.S. Department of Health and Human Services Office of the Inspector General estimated a total of $13.6 billion in state and federal TPL savings during a one-year period.

It’s All About Data — Quality, Matching and Security

Effectively managing and maintaining a Medicaid TPL program is no easy feat, particularly given its complex and always-evolving nature.

TPL is heavily reliant on the timeliness and quality of data. This can require significant internal resources to manage TPL data sources and ensure data is verified for optimal cost avoidance.

Data matching is yet another element of TPL complexity. There are two main sources of information that states can use to determine whether there is a liable third party for a specific claim. One is the individual Medicaid enrollee, and the other is data matching with data clearinghouses or other insurers.

An experienced TPL partner will have the expertise, innovation and interoperability to provide states the advanced analytics, machine learning tools and best practices they need to accurately match individuals to third-party coverage. And we can’t express strongly enough the importance of having a single source of truth and accurate information from the start of the coordination of benefits process; it is vital to a TPL program’s success.

Experience Matters

The TPL process is complex, but it’s something Gainwell has mastered over the years. We have long been the nation’s leading provider of TPL services across quality, speed, price and results. Other TPL vendors have thrown their proverbial hats into the ring, but none of them even come close to the amount of dollars we’ve recovered for our clients.

Today, Gainwell provides TPL services to a large majority of the nation’s Medicaid agencies. We process 1 billion claims annually and save our clients approximately $5 billion per year through cost avoidance and coordination of benefits recoveries.

To learn more about our Pre-payment Solutions for state agencies and CMS-certified modular, cloud-based Medicaid Management services, visit