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.

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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.

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MILLIONS DUALLY ENROLLED IN MEDICAID AND MARKETPLACE PLANS: CMS DATA WOULD SUGGEST ELIGIBILITY SYSTEM OVERHAUL

 

A new report from the Centers for Medicare & Medicaid Services (CMS) has revealed that millions of individuals were enrolled in multiple publicly funded health plans during 2024, raising significant concerns about duplicate coverage and unnecessary spending within the Medicaid program. 

Duplicate Medicaid enrollments are costing the program billions of dollars. According to the data, 1.2 million people were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) across more than one state. At the same time, another 1.6 million individuals had simultaneous coverage under both Medicaid and an ACA Marketplace plan.

For Medicaid Managed Care Organizations (MCOs) and their Coordination of Benefits (COB) and Third-Party Liability (TPL) teams, this news reinforces a challenge they face daily: the issue of improper payments. These departments work diligently to ensure accurate coverage identification and prevent unnecessary claim payments. However, despite their rigorous efforts, many duplicate enrollments are only uncovered after services have been provided and payments have been made, forcing plans to engage in resource-intensive recovery efforts.

Outdated systems, slow eligibility feeds, and fragmented data between state and federal programs make it nearly impossible for plans to identify overlapping enrollments in real-time, proactively.

“Plans aren’t failing to do the work. They’re being asked to manage a national-scale eligibility challenge without the modern tools required to solve it,” noted one industry expert.

These enrollment overlaps have profound implications: inefficient spending of taxpayer dollars, disrupted provider reimbursements, and confusion for members navigating their benefits. More importantly, they highlight the limits of current infrastructure and the need for modern, integrated, real-time data.

To address these gaps, CMS’s findings underscore what Medicaid plans have been emphasizing for years—technology and data modernization are essential. Many MCOs have developed internal processes to detect suspicious enrollment patterns, but without comprehensive, up-to-date data, true cost avoidance remains beyond reach.

Maintaining Medicaid’s role as a dependable safety net will require coordinated investment in new systems that allow for interoperability, consistent eligibility tracking, and early detection of dual coverage. These tools will enable plans to prevent improper payments instead of recovering them after the fact.

With 2.8 million overlapping enrollments identified in a single year, the urgency is clear. Medicaid plans are already committed to protecting program resources. Now, they need the tools and data to support a proactive, prevention-first approach.

Find out more here. 

JUNE 2025 MEDICAID NEWS ROUNDUP

 

Stay informed with Syrtis Solutions’ monthly Medicaid news update! Each month, we deliver key insights on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to tackle improper payments, fraud, waste, and abuse. Our roundup highlights critical policy changes, research findings, and legislative updates shaping the Medicaid landscape. Here’s a recap of last month’s top Medicaid news.

 Read the news. 

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.