MEDICAID IMPROPER PAYMENTS & UNREPORTED COMMERCIAL COVERAGE: A RAPIDLY ESCALATING BUDGET THREAT

 

Medicaid improper payments have become one of the most serious pressures facing Medicaid programs today. In 2024 alone, these errors totaled $31.1 billion, consuming funds that states cannot afford to lose. A large share of this waste occurs when Medicaid unknowingly pays claims that should have been billed first to a commercial insurer. This problem persists because states lack timely, accurate visibility into whether a beneficiary holds other health insurance.

Nearly 10 percent of Medicaid members currently have commercial coverage that is never identified by traditional processes. States continue to rely on eligibility files that lag behind reality, outdated verification systems, and fragmented coordination of benefits workflows. With these limitations, Medicaid ends up paying incorrectly—and the recovery efforts that follow rarely reclaim more than a fraction of the dollars that should never have gone out in the first place. Every one of these improper payments represents a preventable loss that weakens the program and limits the services it can support.

THE BIG BEAUTIFUL BILL: AN ENVIRONMENT OF TIGHTER CONSTRAINTS

The financial stakes will rise even higher under the Big Beautiful Bill, which imposes new federal constraints on how states can operate and fund their Medicaid programs. The law tightens eligibility rules, reduces flexibility around revenue generation, and places states in the difficult position of having to either increase funding or cut benefits and services.

With less room to maneuver, the need to control unnecessary spending becomes urgent. Preventing improper payments through accurate identification of third-party liability (TPL) is no longer optional—it is essential to protecting Medicaid’s financial foundation.

SYRTIS SOLUTIONS DELIVERS REAL-TIME COST AVOIDANCE

Syrtis Solutions helps Medicaid programs confront this challenge directly by stopping improper payments before they occur. ProTPL, the company’s real-time TPL technology, identifies unknown commercial coverage before Medicaid becomes the payer. Through exclusive access to the country’s largest ePrescribing network, ProTPL provides a level of visibility that traditional vendors cannot match.

Medicaid payers that implement ProTPL routinely discover significantly more commercial coverage—often about 25 percent more than their legacy processes reveal. This leads to immediate reductions in improper payments and dramatically lowers the dependence on slow, resource-heavy pay-and-chase models. Instead of chasing lost dollars, states keep those dollars inside the Medicaid program where they belong.

ProTPL integrates seamlessly with existing systems, requires minimal operational disruption, and fully supports federal TPL compliance requirements. With a transaction-based pricing model and a proven history of success among major health plans, Syrtis Solutions offers a reliable and scalable way to strengthen program integrity, preserve provider relationships, and safeguard strained budgets.

UNCOVER THE SAVINGS YOU’RE MISSING

To help Medicaid payers quantify their exposure, Syrtis offers a free claims analysis that evaluates the plan’s own data. This review identifies gaps in current TPL workflows and highlights avoidable spending that may be slipping through undetected. These insights often reveal savings opportunities that can have an immediate impact on financial performance.

For states facing intensified budget pressure and shrinking flexibility, identifying these opportunities early can support smarter decision-making, stronger oversight, and long-term fiscal stability.

Discover more here. 

MEDICAID UPDATES & HIGHLIGHTS – OCTOBER 2025

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.

Continue reading here. 

MEDICAID COB: REAL-TIME SOLUTIONS TO PROTECT BENEFITS AND REDUCE WASTE

Medicaid COB sits at the intersection of fiscal responsibility and patient protection. As states face historic funding challenges, efficiency is no longer optional—it’s essential. The Medicare Rights Center recently reported that multiple states are already cutting back provider rates and optional services in anticipation of substantial federal reductions, projected to total $1 trillion over the next decade.

Such cuts pose real risks to access and quality of care. But benefit reductions are not the only—or even the best—solution. State Medicaid agencies and MCOs can achieve major savings by closing administrative gaps and improving payment accuracy. The key is ensuring Medicaid pays only when truly responsible, which hinges on more effective coordination of benefits and third-party liability management.

Syrtis Solutions’ article, Improper Payments: Medicaid’s Billion-Dollar Problem, underscores that billions in claims each year are misallocated because Medicaid lacks timely visibility into other coverage. The consequence is an inefficient “pay and chase” cycle that rarely recovers its full cost.

By contrast, modern technology now allows for real-time primary coverage identification within Medicaid COB. ProTPL, Syrtis Solutions’ proprietary coverage identification platform, integrates directly with claims processing systems to detect active third-party coverage before payment. This pre-payment verification eliminates redundant spending and demonstrates immediate ROI for both states and MCOs.

The Centers for Medicare & Medicaid Services (CMS) reports that Medicaid’s improper-payment rate reached 5.09 percent in FY 2024, accounting for $31 billion in losses. Nearly 80 percent stemmed from preventable administrative issues rather than fraud or abuse. This represents a massive opportunity for improvement through data-driven solutions like ProTPL.

Real-time COB and TPL technology allow Medicaid plans to move from reactive to proactive management. Instead of chasing dollars after the fact, states can stop the overpayment at the source. For members, that means uninterrupted access to needed services. For taxpayers, it means smarter stewardship of public funds.

Cost Avoidance in Medicaid COB offers a practical way to reduce waste while preserving benefits. As fiscal challenges mount, it’s imperative that states pursue innovation rather than austerity. With the right systems in place, every Medicaid dollar can be accounted for, and every member can receive the coverage they deserve.

Syrtis Solutions’ ProTPL delivers this capability today—enabling Medicaid programs to meet rising demands, comply with integrity standards, and maintain the trust of those they serve. The future of Medicaid depends on efficiency, transparency, and prevention. Real-time COB and TPL innovation make that future possible.

Learn more here. 

MEDICAID NEWS RECAP – SEPTEMBER 2025

 

Stay informed with Syrtis Solutions' monthly Medicaid news summary! Each month, we bring you the latest updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to combat fraud, waste, and abuse. Our roundup highlights key policy changes, research insights, and legislative developments impacting the Medicaid landscape. Here’s a look at last month’s most important Medicaid news.

Read more. 

MEDICAID UPDATES & HIGHLIGHTS – AUGUST 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.

Find out more. 

GAO REPORT REINFORCES URGENCY OF TACKLING MEDICAID IMPROPER PAYMENTS

 

In August 2025, the Government Accountability Office (GAO) published GAO-25-108067, outlining 32 open priority recommendations for the Department of the Treasury. The report highlights several systemic challenges facing federal agencies, with the foremost being the need to reduce fraud and improper payments.

The GAO estimates that between $233 billion and $521 billion is lost each year due to fraud. Since 2003, improper payments reported across government programs have totaled nearly $2.8 trillion, with Medicaid consistently among the leading drivers of these errors. For the past seven years, improper payments have topped $150 billion annually.

To curb these losses, the GAO called on the Treasury and the OMB to:

• Expand fraud estimation models and leverage analytics in high-risk programs, such as Medicaid.

• Strengthen recovery audits and post-payment reviews to identify and reclaim erroneous disbursements.

• Direct resources toward the riskiest programs, with Medicaid prominently on that list.

GAO cautioned that as time passes, recovering overpayments becomes increasingly unlikely.

Medicaid’s Billion Dollar Problem

The findings align with the analysis presented in Syrtis Solutions’ white paper, "Improper Payments: Medicaid’s Billion-Dollar Problem." Improper payments in Medicaid often result from:

• Errors in eligibility and enrollment

• Incomplete coverage verification

• Coordination of benefits (COB) breakdowns

While the GAO emphasizes corrective steps after payments are made, Syrtis Solutions highlights the measurable value of preventing improper payments upfront. Through its ProTPL solution, Syrtis provides real-time access to verified other health insurance (OHI) and third-party liability (TPL) information. This enables managed care organizations (MCOs) to avoid paying claims that are the responsibility of other third parties, thereby reducing the likelihood of improper payments.

Strengthening Medicaid Program Integrity

Improper payments have long undermined Medicaid’s financial integrity. The GAO’s report underscores the urgency for the Treasury and OMB to enhance oversight, but there is also a clear role for states and MCOs to act immediately.

Data-driven strategies such as proactive COB and TPL detection have delivered ROI ratios above 15:1, preventing millions in unnecessary Medicaid expenditures while protecting funds for eligible members.

GAO’s 2025 report makes clear that improper payments remain a systemic issue across federal programs. Medicaid, as one of the most significant sources of vulnerability, requires both strong federal oversight and the adoption of proactive solutions at the plan level. With proven tools like ProTPL, Syrtis Solutions continues to help states and MCOs safeguard Medicaid funds, improve accuracy, and achieve sustainable savings.

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MEDICAID DEVELOPMENTS & INSIGHTS – JULY 2025

 

Stay informed with Syrtis Solutions' monthly Medicaid news summary! Each month, we bring you the latest updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to combat fraud, waste, and abuse. Our roundup highlights key policy changes, research insights, and legislative developments impacting the Medicaid landscape. Here’s a look at last month’s most important Medicaid news.

Click here to read more.