05 Mar The Clock is Ticking: Protecting Medicaid Budgets by Eliminating Improper Payments
The latest House budget proposal presents serious threats to Medicaid funding, potentially cutting billions from state programs. With these looming reductions, Medicaid agencies and Managed Care Organizations (MCOs) must take immediate action to maximize every dollar spent. One of the most effective ways to achieve this is by addressing the chronic issue of improper claims payments, which cost Medicaid over $80 billion annually.
The Problem: Medicaid’s Costly Inefficiencies
Improper Medicaid payments have been a persistent issue for nearly two decades, consistently landing the program on the Government Accountability Office’s (GAO) high-risk list. While fraud is often cited as a concern, the reality is that outdated data systems and inefficient coordination of benefits (COB) are the primary culprits behind these losses.
- Medicaid is legally the payer of last resort, meaning any other available health coverage should pay first. Yet, over 13% of Medicaid enrollees have unreported third-party liability (TPL), leading to unnecessary payments.
- Eligibility data is outdated and fragmented across state and federal systems, making it difficult to identify primary coverage before claims are paid.
- The current “pay and chase” model is ineffective, recovering only a fraction of the dollar amount for improper claims payments.
With impending budget cuts, these inefficiencies are no longer just a policy concern—they are an existential threat to Medicaid’s sustainability.
The Solution: Cost Avoidance Through Better Data
Rather than continuing the costly cycle of improper payments and retroactive recoveries, MCOs and Medicaid agencies must shift to cost avoidance—ensuring primary payers are billed before Medicaid ever spends a dollar. This requires real-time, accurate eligibility data that enables MCOs and Medicaid agencies to identify other health insurance (OHI) coverage before claims are paid.
Syrtis Solutions provides a proven solution to this problem through its proprietary technology, ProTPL. This system leverages ePrescribing data, the most accurate and timely source of commercial health coverage information, to:
- Increase TPL discovery by up to 40% beyond existing processes.
- Deliver real-time OHI data at the point of claim submission, reducing improper payments upfront.
- Eliminate the need for “pay and chase”, significantly cutting administrative waste.
Why Now? The Urgency of Action
With Medicaid budgets on the chopping block, states and MCOs must act now to protect critical services and ensure program sustainability. The days of accepting massive losses from improper payments are over. Every dollar wasted on an unnecessary claim is a dollar taken away from essential healthcare services. Implementing cost avoidance strategies is not just a best practice—it is a necessity in the face of budgetary threats. Syrtis Solutions provides the most effective and immediate pathway to reducing waste and maximizing Medicaid’s financial resources.
Don’t wait for budget cuts to force change. Be proactive. Take control. Protect Medicaid.
Contact us at info@syrtissolutions.com today to learn how ProTPL can help your organization save millions and secure the future of Medicaid funding.