29 Mar MEDICAID IMPROPER PAYMENTS TOTALED $50.3 BILLION IN ’23
A recent audit by the U.S. Government Accountability Office reveals that the federal government suffered a staggering loss of $236 billion in 2023 due to improper payments. Medicaid and Medicare alone accounted for 43% of these payments, with Medicaid’s improper payments reaching $50.3 billion. These findings underscore the urgent need to address improper payments, which often stem from eligibility errors and outdated data systems, not rampant fraud and abuse.
By law, Medicaid functions as the payer of last resort, meaning it covers healthcare costs only after other third-party payers fulfill their obligations. However, identifying these third-party payers has become increasingly difficult as the program expands due to insufficient access to quality eligibility data. This lack of accurate data has led to billions in improper payments for Medicaid plans.
When Medicaid plans discover improperly paid payments, they use a “pay and chase” process to recoup funds. This approach has created a multibillion-dollar post-payment recovery industry, but unfortunately, for payers of last resort, only 20 cents on the dollar is recovered.
The struggle to identify liable third-party payers has persisted for decades, exacerbated by the absence of technology capable of accurately pinpointing active and accurate OHI. Despite legislative efforts and federal initiatives to curb improper payments, the problem has persisted, leading to Medicaid’s inclusion on the Government Accountability Office’s high-risk list for twenty consecutive years.
How can payers of last resort mitigate improper payments?
To mitigate the need for post-payment recovery, Medicaid payers must gain access to timely and accurate eligibility data. Leveraging ePrescribing infrastructures presents a promising solution, as they house some of the most reliable and current data on patients’ health insurance coverage.
Recognizing this potential, Syrtis Solutions has developed ProTPL, a technology-based solution that utilizes ePrescribing eligibility data to help Medicaid plans proactively identify primary payers. ProTPL enables Medicaid plans to avoid erroneous claims costs upfront by using proprietary logic and advanced matching algorithms, streamlining the claims process for all stakeholders involved.
Syrtis Solutions’ ProTPL addresses the root cause of improper payments by harnessing better data and applying it to prevent erroneous claims payments. With ProTPL, Medicaid plans across the country are reducing costs and improving the efficiency of their claims management processes.