Third Party Liability Identification and Collection from Insurance Companies at the Florida Department of Health and Rehabilitative Services

EXECUTIVE SUMMARY:

This audit report provides the results of our audit of the Third Party Liability Identification and Collection from Insurance Companies at the Florida Department of Health and Rehabilitative Services (DHRS) for the period of July 1, 1989 through June 30, 1991. The objective of our review was to determine whether the Florida DHRS had established a system of accountability for third party liability (TPL) under the Medicaid program. During this audit we examined: (1) insurance payments (2) the validity of outstanding insurance company billings, and (3) collections from the insurance companies. Our review disclosed that DHRS had not sought reimbursement from Blue Cross and Blue Shield of Florida, Inc. (BCBSF) since January 1989 for 305,230 claims with potential TPL. These claims were not billed because DHRS suspended its submission of paper claims to BCBSF until an electronic billing medium could be designed and implemented by the fiscal agent. The 305,230 claims totaled $8,539,398 (Federal share of $4,661,089).