Medicaid currently fails at providing a system that efficiently and accurately stores and utilizes member data. As Medicaid is a joint state and federally run program, there are many problems with coordinating data platforms. Different states have their own unique data processing and storing, and...
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...
The Social Security Act, signed into law by President Franklin Roosevelt in 1934, specifies in statute § 1902( a)( 25) of the law "...
Improper payments cost Medicaid $86.49 billion in 2020 alone. A common misconception is that improper payments come from fraud and abuse when in reality the majority come from prosaic, ordinary problems such as eligibility errors and antiquated data systems. Fraud in Medicaid may well still...
Since Medicaid’s inception in 1965, the program has expanded to become the largest provider of healthcare coverage in the country. As the member population size has grown, Medicaid third party liability (TPL) efforts and fiscal responsibility have been reoccurring issues. To protect Medicaid’s solvency, there...
Identifying third party liability continues to be a challenge under the coordination of benefits for Medicaid plans. By law, plans are payers of last resort so whenever beneficiaries have other active coverage (OHI), those third parties should pay first. Currently, Medicaid plans are required to...
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...
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...
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...