30 Nov MEDICAID IMPROPER PAYMENTS & UNDISCLOSED COMMERCIAL COVERAGE: A FINANCIAL CHALLENGE STATES FACE
Medicaid’s financial vulnerability became even more visible in 2024 as Medicaid improper payments climbed to $31.1 billion. These losses are not incidental—they represent systemic shortcomings that drain state budgets and weaken the program’s ability to meet growing demand. A major driver behind this escalating problem is the persistent inability to identify commercial insurance that should be the primary payer.
At any moment, approximately one in ten Medicaid members carries commercial coverage that remains unreported or undiscovered. Legacy coordination of benefits processes rely heavily on outdated eligibility files, inconsistent verification routines, and technology that cannot keep pace with real-time coverage changes. As a result, Medicaid pays claims that a commercial insurer should have absorbed, and the subsequent recovery efforts reclaim only a fraction of the initial loss. This cycle leaves states with millions in preventable expenses that could have been avoided with better visibility.
THE BIG BEAUTIFUL BILL: NEW PRESSURES, SHRINKING MARGINS
The upcoming federal changes under the Big Beautiful Bill will add yet another layer of financial strain. The legislation tightens Medicaid financing rules by restricting eligibility flexibility, imposing new revenue constraints, and limiting states’ ability to patch budget shortfalls. With less room to maneuver, states will be forced to make increasingly difficult decisions about which services and benefits can be preserved.
In this constrained environment, preventing improper payments is no longer optional—it is an essential component of fiscal survival. Ensuring Medicaid pays only after all other liable insurers have been billed is one of the few strategies that directly and immediately protects state budgets.
SYRTIS SOLUTIONS: REAL-TIME COVERAGE DISCOVERY THAT ELIMINATES WASTE
Syrtis Solutions provides Medicaid payers with a direct, proactive way to stop improper payments before they occur. ProTPL, its real-time cost-avoidance solution, identifies unknown commercial coverage at the point of service. Its advantage lies in exclusive access to the nation’s largest ePrescribing network, enabling ProTPL to surface primary coverage that traditional TPL vendors routinely miss.
States and health plans using ProTPL report around 25% more discovered commercial coverage compared to conventional methods. This translates into fewer erroneous Medicaid payments and a substantial reduction in pay-and-chase activity. Because ProTPL prevents the payment from going out in the first place, savings stay in the Medicaid program instead of being pursued after the fact.
ProTPL is designed for minimal disruption, integrates smoothly with existing processes, supports federal TPL mandates, and operates alongside other vendors. Its transaction-based model offers predictable, scalable value. Major payers nationwide depend on Syrtis Solutions to stabilize budgets, reduce administrative burden, and strengthen overall program integrity.
A CLEARER VIEW OF SAVINGS OPPORTUNITIES
To help Medicaid payers understand the true extent of their exposure, Syrtis provides a complimentary claims analysis. By evaluating the plan’s actual claims data, this assessment identifies where commercial coverage is being missed and quantifies how much preventable spending is occurring.
The insights generated often reveal:
- Hidden areas of improper payment risk
- Coverage that should have been identified but wasn’t
- Meaningful, actionable savings that can be captured immediately
For programs navigating tightening financial constraints, uncovering these savings opportunities early can influence budget planning, improve operational efficiency, and support long-term sustainability.