In the previous post, I discussed how ProTPL uses Rx claims to "trigger" cost avoidance, not only for pharmacy claims, but for medical claims as well. In the case study that started in 2012, we see how this is put into practice. There are two key...
When ProTPL discovers other health insurance, you can reverse the latest claim and ensure that future claims, whether pharmacy or medical, aren’t paid in error. Discovering other health insurance fast, triggered by Pharmacy claims, allows you to intercept the medical claims, such as office or...
Members of the House Energy and Commerce Committee and Senate Finance Committee sent out a letter to associations serving Medicaid health plans in pursuit of suggestions on best practices connected to cost controls, the use of data and quality of care. The leaders want to gain a...
Third parties are organizations or people who are legally liable for paying the healthcare claims of Medicaid beneficiaries. Federal legislation and policies mandate states to guarantee that Medicaid is to be the payer of last resort. Medicaid beneficiaries are consequently obligated to utilize all other...
With the increased awareness that government officials have paid to the need for accurate Medicaid claims information within federal government healthcare systems, one may have expected that now, nearly two years since an inspector general testified that much of the data used to identify improper...
The intent of the Effective Practices Guide, presented by CMS in collaboration with various state COB/Third Party Liability units is to provide state Medicaid agencies with information on practices that could assist states in improving their identification and successful pursuit of legally liable third party...
It’s not easy to discover primary commercial coverage on your plan’s members at the point of sale—costing you time and money chasing reimbursements for claims that others should have paid. And so far with little luck: on average less than 17% of the money billed...
In a one year case study with a Medicaid plan, we found that, on average, 1.3% of utilizing members where identified as having other insurance. In other words, Syrtis processed nearly 3 million pharmacy claims and returned approximately 38,000 members identified with other primary insurance....
Syrtis Solutions developed ProTPL, a real-time point of sale cost avoidance service for the payer of last resort market. ProTPL offers the most active and current primary pharmacy coverage information from any vendor in the market. Up to 4 times more coverage information! ..and in real-time, at...
The watchdog for the U.S. Congress, the Government Accountability Office (GAO), designates Medicare and Medicaid as a high-risk plans, because it’s a complicated program, which is in danger from fraudulent activity. Fraud, in this case, involves deception resulting in a profitable gain at the expense...
