MAY 2025 MEDICAID NEWS ROUNDUP

 

Stay up to date with Syrtis Solutions' monthly Medicaid news roundup! Each edition delivers the latest updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to combat fraud, waste, and abuse. We cover key policy changes, legislative developments, and research insights shaping the Medicaid landscape. Here’s a recap of last month’s most important Medicaid news.

See the news. 

MEDICAID REFORM AND TECHNOLOGIES HELP STATES CUT COSTS

As Medicaid enrollment swells and costs continue to rise, while budget cuts are being considered, state governments are reaching a critical decision point. What was already one of the most expensive state programs has become even more costly, now accounting for close to 33% of many state budgets. Pandemic-era protections and Medicaid expansion policies helped millions gain coverage, but they also exposed systemic inefficiencies that states can no longer afford to overlook.

Now, with post-pandemic budget tightening underway, states are taking a hard look at how to rein in Medicaid spending without compromising access to care.

A DECADE OF BILLIONS LOST TO IMPROPER PAYMENTS

Improper payments remain one of Medicaid’s most persistent and expensive problems. In fiscal year 2023, more than $50 billion in payments were made in error, according to CMS. The primary culprits? Poor documentation and weak eligibility verification.

Improper Medicaid payments have topped half a billion dollars over the last ten years—money that could have been redirected to essential services or stretched existing healthcare budgets further. For states already facing economic headwinds, these avoidable losses are unsustainable.

STATES ENACT REFORMS TO STRENGTHEN PROGRAM OVERSIGHT

In response, many states are advancing legislation and policy changes to bring accountability and accuracy back to Medicaid operations:

• Indiana eliminated self-attestation in favor of regular eligibility checks using government databases and implemented quarterly reporting on fraud prevention efforts.

• Texas has expanded the use of third-party and federal tax data to verify Medicaid eligibility and has invested in modernized systems to increase automation and accuracy.

• Florida and Missouri are doubling down on frequent eligibility redeterminations and greater scrutiny of Managed Care Organizations (MCOs).

• Arkansas and Georgia have rolled out stricter redetermination schedules and automated eligibility verification to reduce enrollment errors.

These actions reflect a coordinated shift toward data-driven oversight and stricter controls to prevent ineligible individuals from remaining on the rolls.

TECHNOLOGY: THE ENABLER OF REAL-TIME INTEGRITY

To make these policies effective and scalable, states are increasingly adopting purpose-built technologies that can automate and enhance the integrity of the Medicaid program. One such solution is ProTPL from Syrtis Solutions—a real-time third-party liability detection platform.

ProTPL helps Medicaid programs meet federal coordination of benefits (COB) requirements and improve cost avoidance by:

• Flagging claims with existing commercial coverage before payment is issued,

• Automating verification tasks that would otherwise require manual follow-up,

• Minimizing administrative overhead while improving audit readiness,

• Ensuring that Medicaid remains the payer of last resort, as intended by law.

By shifting from “pay-and-chase” recovery tactics to preemptive cost avoidance, ProTPL supports faster, cleaner operations while saving states millions.

A MODERN MEDICAID SYSTEM REQUIRES BOTH POLICY AND TECH

For Medicaid to remain sustainable, states need to rethink not just what is being done, but also how it is being done. The best policy in the world can’t succeed if the systems enforcing it are outdated or underpowered. That’s why the combination of reform-driven governance and real-time technology is emerging as the most effective strategy.

States that align legislative reform with innovations like ProTPL will be better equipped to:

• Protect public funds,

• Deliver accurate, timely care,

• And restore confidence in the long-term viability of Medicaid.

This is not just about fixing what’s broken—it’s about building a smarter, stronger Medicaid program that can adapt to modern demands.

Click this link to learn more. 

MEDICAID UPDATES & HIGHLIGHTS – APRIL 2025

 

Stay informed with Syrtis Solutions’ monthly Medicaid news roundup! Each month, we provide essential updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to prevent fraud, waste, and abuse. Our summary highlights key policy changes, legislative updates, and research insights shaping the Medicaid landscape. Here’s a look at last month’s top Medicaid news.

View the highlights. 

Medicaid Updates & Highlights – March 2025

Stay informed with Syrtis Solutions’ monthly Medicaid news roundup! Each month, we provide essential updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to prevent fraud, waste, and abuse. Our summary highlights key policy changes, legislative updates, and research insights shaping the Medicaid landscape. Here’s a look at last month’s top Medicaid news.

Learn more here. 

 

$880 BILLION IN PROPOSED MEDICAID CUTS: MCOS AT A CRITICAL CROSSROADS

 

As of March 18, Medicaid Managed Care Organizations (MCOs) are facing a major financial reckoning. A proposed federal budget outlines $880 billion in Medicaid cuts over the next decade—an unprecedented shift that could redefine how healthcare is accessed, managed, and funded for millions of Americans. With tighter margins on the horizon, MCOs are being pushed to rethink every aspect of their operations.

---

Budget Cuts: What’s on the Line?

The proposed reductions signal more than just smaller checks from Washington. If enacted, they will likely trigger stricter eligibility requirements, decrease overall enrollment, and reduce the scope of covered services. This translates to immediate financial pressure on MCOs—who must continue delivering essential care with fewer resources.

The challenge isn’t just about managing losses—it’s about reengineering systems to do more with less.

---

Targeting Inefficiencies: A Vital First Step

Improper payments remain a persistent drain on Medicaid. Billing errors, duplications, and fraudulent claims cost the system billions every year. For MCOs, cracking down on these issues offers a clear path to financial stability. Technologies that enable real-time claims validation, predictive analytics, and automated red flags can significantly cut waste and reinforce program integrity.

---

State Strategies in Action

States are already taking matters into their own hands in anticipation of future funding constraints:

• California has infused $3.4 billion from its general fund into Medi-Cal, responding to increased utilization and expanding coverage to undocumented individuals. It’s a stopgap measure—but one that highlights the scale of the pressure.

• Kentucky lawmakers are exploring cost-control tactics that maintain care standards. Their focus is on optimizing efficiency, trimming bureaucratic fat, and future-proofing the system.

• Iowa officials are doubling down on fraud prevention, believing that rooting out abuse is the best way to preserve services without reducing coverage.

---

Tech Innovation: The New Backbone of Medicaid Ops

In this climate, manual processes and outdated systems are no longer sustainable. MCOs are increasingly turning to tech-enabled solutions to enhance performance. Companies like Syrtis Solutions are leading the way, offering platforms that help verify patient eligibility, reduce redundant claims, and flag irregularities before they result in overpayments.

Adopting such technology is becoming a competitive necessity—helping MCOs improve outcomes while staying within budget.

---

The Way Forward: Resilience Through Reform

For Managed Care Organizations, the path ahead is complex—but not without opportunity. The organizations that will thrive in this environment are those that lean into transparency, adopt smarter systems, and proactively respond to shifting policy landscapes. Reducing improper payments, leveraging innovation, and aligning closely with state-level initiatives will be key to long-term viability.

Medicaid is evolving. The question is: how fast can MCOs evolve with it?

Click here to continue learning. 

THE IMPACT OF MEDICAID BUDGET CUTS AND STATE-LEVEL RESPONSES

As federal budget cuts threaten Medicaid funding, states are taking different approaches to safeguard healthcare access for millions of residents. With financial uncertainties looming, strategic planning and policy adjustments are becoming essential for maintaining program sustainability. Here’s how key states are addressing these fiscal challenges.

California’s Financial Crisis and Response

California’s Medicaid program, Medi-Cal, is grappling with a $3.4 billion shortfall, forcing the state to tap into its general fund. The deficit is driven by growing enrollment, increased medical costs, and expanded eligibility. Policymakers are exploring long-term strategies, including cost containment and alternative revenue sources, to stabilize the program.

Kentucky’s Focus on Cost Efficiency

In Kentucky, legislators are examining Medicaid spending to identify areas where efficiency can be improved without compromising coverage. Lawmakers are considering ways to reduce administrative costs and eliminate redundancies while maintaining vital services for the state’s low-income population.

Louisiana’s Investment in Medicaid

Local leaders are voicing alarm over proposed federal funding reductions that could disrupt vital services, including Medicaid and crisis response centers. The cuts threaten to limit healthcare access for at-risk individuals, strain local resources, and reduce the availability of essential mental health and substance abuse programs. Officials are working on strategies to mitigate the impact and safeguard support for those who depend on these critical services.

Iowa’s Crackdown on Fraud

Iowa lawmakers, including Representative Ashley Hinson, are prioritizing fraud prevention as a means to curb Medicaid costs. By implementing stricter oversight and fraud detection measures, the state hopes to reduce financial waste while ensuring that legitimate beneficiaries retain access to necessary healthcare services.

West Virginia’s Push Against Medicaid Reductions

Advocacy groups in West Virginia are rallying against proposed Medicaid cuts, arguing that such reductions could disproportionately affect vulnerable populations. Healthcare professionals and community leaders stress the importance of maintaining funding to prevent service disruptions for those most in need.

The Road Ahead for Medicaid Programs

With federal budget cuts looming and financial pressures rising, states and Medicaid programs must take strategic action to safeguard funding and ensure the longevity of essential healthcare services. To strengthen Medicaid’s financial stability, states and managed care organizations (MCOs) should focus on eliminating improper payments, enhancing fraud prevention, and improving operational efficiency. By maximizing the effective use of resources, Medicaid can continue to serve vulnerable populations while maintaining fiscal responsibility in an increasingly uncertain economic climate.

Learn more.

MEDICAID UPDATES & HIGHLIGHTS - FEBRUARY 2025

 

Stay informed with Syrtis Solutions’ monthly Medicaid news roundup! Each month, we provide essential updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to prevent fraud, waste, and abuse. Our summary highlights key policy changes, legislative updates, and research insights shaping the Medicaid landscape. Here’s a look at last month’s top Medicaid news.

Read here.