Cost avoidance is becoming a priority for health plans facing pressure to control spending, improve payment accuracy, and protect limited healthcare dollars. With tighter budgets, federal requirements, and increased scrutiny of program integrity, plans need measurable savings that don’t reduce benefits or disrupt member care. That pressure is putting new attention on payment integrity.
Moving Beyond “Pay and Chase”
A September 2026 majority staff report from the House Committee on Energy and Commerce examined fraud and program integrity across Medicare and Medicaid. It highlighted the limits of the traditional “pay and chase” model and pointed toward greater use of data, technology, and analytics to identify payment issues earlier, rather than relying mainly on recovery after dollars have left the program.
The report focuses largely on fraud and improper payments, but the principle applies more broadly to health plans. One of the clearest opportunities lies within the coordination of benefits (COB) and third-party liability (TPL).
Finding Savings by Identifying the Right Payer
Medicaid is generally the payer of last resort. When a member has other liable insurance, that coverage typically has primary payment responsibility, making accurate and timely identification of other coverage essential.
The challenge is that commercial coverage changes frequently. Members change employers, gain coverage through a spouse or parent, move between plans, or acquire insurance that doesn’t immediately appear in a plan’s data. When that coverage is unknown, Medicaid may pay a claim another insurer should have covered. If it’s discovered later, the plan has to pursue recovery. If it’s identified early enough to affect the claim, the expense can be avoided altogether.
Retrospective recovery remains an important part of COB/TPL, but it requires additional time, resources, and reconciliation. For plans that already operate COB/TPL programs, the opportunity isn’t to replace those processes. It’s to improve the information feeding them.
Traditional eligibility and coverage data can be incomplete, outdated, or unavailable when claims are processed, leaving a gap between the coverage that exists and the coverage the plan knows about.
Automated algorithmic analysis and insurance discovery engines (AAAIDE) can help close that gap by identifying active commercial coverage that may otherwise go unidentified. Better coverage data helps plans determine primary payer responsibility, improve COB/TPL accuracy, and reduce unnecessary Medicaid spending.
Measuring Savings Differently
Recoveries are easy to quantify: the payment happened, and the recovered dollars can be reported. Successful cost avoidance is harder to see because the unnecessary expenditure never occurs.
A September 2026 KFF analysis of Medicaid program integrity made a similar point, noting that recovery statistics don’t fully capture the value of prevention or payments stopped before they occur.
For plans under financial pressure, that distinction matters. Payment integrity should be measured not only by dollars recovered after payment, but also by dollars the plan never had to spend.
A More Complete Strategy
A more complete COB/TPL strategy combines both approaches: recover payments when other coverage is identified after the fact while using better coverage data to create more opportunities for cost avoidance.
Through ProTPL, Syrtis Solutions uses automated algorithmic analysis and insurance discovery to identify other active commercial pharmacy and medical coverage. The goal isn’t to eliminate retrospective recovery. It’s to pair recovery with earlier, better coverage information so plans can recover when information becomes available after the fact and avoid the expense whenever other coverage can be identified sooner.
Cost avoidance gives Medicaid health plans a way to generate measurable savings without cutting benefits, changing reimbursement, or limiting access to care. By strengthening COB and commercial insurance discovery, plans can turn their payer-of-last-resort responsibility into a meaningful cost-containment strategy—helping ensure Medicaid pays only when Medicaid is responsible.
