06 Mar MEDICAID’S FUTURE IS AT RISK: STOP IMPROPER PAYMENTS BEFORE IT’S TOO LATE
With the latest House budget proposal threatening to cut billions from Medicaid, state programs and Managed Care Organizations (MCOs) face an urgent challenge. To sustain healthcare services and maximize every dollar, Medicaid agencies must take immediate action to reduce financial waste. One of the most effective ways to do this is by addressing improper payments, a long-standing issue that costs Medicaid more than $80 billion annually.
The Problem: Medicaid’s Costly Payment Errors
For nearly two decades, Medicaid has been placed on the Government Accountability Office’s (GAO) high-risk list due to improper payments. While fraud is often cited as a concern, the truth is that outdated data systems and poor coordination of benefits (COB) are the real culprits.
Medicaid is required to be the payer of last resort, meaning that if a patient has other insurance, that coverage should be billed first. However, Medicaid continues to make unnecessary payments because:
- Hidden Third-Party Liability (TPL): More than 13% of Medicaid enrollees have unreported private insurance, leading Medicaid to pay claims it shouldn’t.
- Disjointed and Outdated Data: Medicaid eligibility records are fragmented across state and federal systems, making it difficult to verify primary insurance coverage before paying a claim.
- The Ineffective “Pay and Chase” Model: Medicaid attempts to recover improper payments after they’ve already been made, but only a fraction of the lost money is ever recovered.
With looming budget cuts, these inefficiencies are no longer just administrative issues—they are a direct threat to the sustainability of Medicaid.
The Solution: Proactive Cost Avoidance
Instead of paying incorrect claims and struggling to recover the money later, Medicaid agencies and MCOs must shift to cost avoidance—ensuring that primary payers are billed before Medicaid covers any claims. This requires real-time access to accurate eligibility data to properly coordinate benefits before a claim is processed.
Syrtis Solutions offers a proven solution with ProTPL, an advanced technology that utilizes ePrescribing data—the most accurate and up-to-date source of commercial health insurance information—to:
✔ Identify up to 40% more TPL cases than traditional methods.
✔ Provide real-time OHI data at the point of claim submission, preventing improper payments upfront.
✔ Eliminate administrative waste, ending the costly and ineffective “pay and chase” process.
Why Immediate Action is Necessary
With Medicaid funding on the line, state agencies and MCOs must act now to protect their budgets. Every dollar lost to improper payments is a dollar taken away from critical healthcare services. The current system is unsustainable, and failing to act will only lead to deeper financial challenges.
Cost avoidance is not just a smart strategy—it is an urgent necessity in the face of financial uncertainty. Syrtis Solutions provides a fast, effective, and proven solution to reduce waste and ensure Medicaid funds are used where they are needed most.
Protect Medicaid’s Future—Take Action Today
Waiting is not an option. Be proactive. Secure Medicaid funding.
Contact us at info@syrtissolutions.com to learn how ProTPL can help your organization save millions and ensure Medicaid dollars go toward patient care—not wasted on unnecessary claims.