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Office of Recovery Services

Bureau of Medical Collections
Frequently Asked Questions


Table of Contents

  1. What is the Bureau of Medical Collections?
  2. What is Cost Avoidance?
  3. What are Health Claims?
  4. What is Personal Injury?
  5. What is Estate Recovery?
  6. What is Medicare Buy-In?
  7. What is Nursing Home Collections?
  8. What is Provider Overpayment and Fraud Collections?

Questions and Answers

What is the Bureau of Medical Collections?

The Bureau of Medical Collections has the responsibility of ensuring that all other resources are used before Medicaid pays for health care and to seek reimbursement from potentially liable third parties after Medicaid has paid for health care.

The Bureau administers several programs including Cost Avoidance, Medicare Buy-In, Nursing Home Collections, Provider Overpayments and Fraud Collections.

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What is Cost Avoidance?

Medicaid is the payer of last resorts. When insurance is available Medicaid claims are denied until the insurance has been billed and the insurance claim is processed. The amount paid by the insurance is used to reduce Medicaid's liability. In the majority of cases where insurance is available Medicaid's liability is reduced to zero.

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What are Health Claims?

If insurance exists and Medicaid has paid a claim that may be covered by the insurance, the Bureau will file a claim for reimbursement of the Medicaid program from the insurance company. The Medical Benefits Recovery Act allows the Bureau to file claims directly with the insurance company. The Act also requires the insurance company to pay the Bureau directly.

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What is Personal Injury?

If a Medicaid Recipient is injured in an accident or through the actions of another person, the Bureau is required to seek reimbursement from any potentially liable third party. This includes automobile insurance, homeowner's insurance, potentially liable companies, or negligent individuals.

The Medicaid program must be reimbursed before other injured parties.

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What is Estate Recovery?

The Bureau is required to identify the assets of deceased Medicaid Recipients who were over the age of 55. The assets of the estate are used to reimburse the Medicaid program.

Reimbursement is only made if there is no surviving spouse, no minor children under the age of 21 or no blind or disabled child.

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What is Medicare Buy-In?

The State will pay the Medicare premiums for Medicaid Recipients. The State will continue to pay the premium for as long as the recipient remains eligible for Medicare.

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What is Nursing Home Collections?

Money left in a personnel use account at a nursing home must be paid to Medicaid to help reimburse Medicaid for the costs of the nursing home.

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What is Provider Overpayment and Fraud Collections?

Overpayments happen when a provider receives a payment from an insurance company after Medicaid has paid for the service or if Medicaid determines that a payment was made in error. The provider must return the overpayment amount to Medicaid.

Provider Fraud occurs when a provider deliberately cheats the Medicaid system. A provider found defrauding Medicaid must repay all payments made by Medicaid.

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