Medicaid has evolved to become an integral safety net program that provides access to health care for millions of Americans. Payment for this health care is either delegated to Medicaid or other third party insurance coverage. In 2012, 7.6 million people on Medicaid had other...
Medicaid payers of last resort face the challenging task of recovering claims payments made in error when program beneficiaries fail to report primary coverage information at the time services are provided. Plan members do not share other coverage information for a multitude of reasons, but...
The Coronavirus pandemic and the consequential economic recession accentuated the importance of the Medicaid program last year. By February, the Medicaid enrollment rate increased to 7.4 percent, and 76.5 million people were enrolled in the jointly funded program. In 2021, the new administration, economy, and...
In addition to rising health care costs and increased spending from the program’s expansion, Medicaid is losing billions of dollars a year from improper payments. Protecting the integrity of the Medicaid program has become a top priority for the Centers for Medicare and Medicaid Services...
In 1965, Title XIX of the Social Security Act established the Medicaid program to provide health care coverage to low-income individuals. Over time it has developed into one of the nation's largest payers for health care, covering one out of five Americans. In FY 2017,...
Since state Medicaid programs are responsible for the healthcare of several populations, skyrocketing prescription drug costs have become a major budgetary concern. Currently, health care spending is dominating many of their budgets and on a per capita basis, inflation-adjusted retail prescription drug spending has increased...
Of the $4 trillion spent by the government in 2017, nearly $141 billion were improper payments. These are payments made in error either to the wrong recipient, in the incorrect amount, or for a service that is not legitimate. Fraud, antiquated data systems, and methodologies...
In 2017, improper payments within the Medicaid program reached a total of $37 billion, according to CMS. That equals 10 percent of the federal dollars spent on the program. Moreover, 99.2 percent of the payments made were overpayments. To make matters worse, under the current...
The federal government must quickly move away from the "Pay and Chase" model where Medicaid routinely makes improper claims payments (those that were the liability of primary insurance plans), then retrospectively identifies the claims with third party liability. To make this change, the government must...
Recently, I got into a discussion with a state Medicaid TPL director about RFPs for third party liability cost avoidance work. I feel that our cost avoidance solution would greatly benefit state-run plans, but RFPs are nearly always written for a single vendor to handle an assortment of...