Wednesday, June 10, 2026
MEDICAID HEADLINES – MAY 2026
Friday, May 29, 2026
DRUG PRICING REFORM AND MEDICAID COST AVOIDANCE: WHY BOTH MATTER
Drug pricing reform is often at the center of discussions about Medicaid cost containment. Whether the focus is prescription drugs, hospital reimbursement rates, or provider payments, the underlying assumption is typically the same: lowering the cost of healthcare services will reduce overall program spending. While pricing initiatives can generate meaningful savings, they address only part of the equation. Before Medicaid can fully benefit from any pricing reform, it must first ensure that claims are being paid accurately and only when Medicaid is the proper payer.
Every year, billions of dollars are spent on claims that were the liability of another primary payer. These expenditures are not necessarily driven by fraud or abuse. More often, they result from incomplete information, delayed data updates, and gaps in visibility at the time a claim is processed.
As policymakers pursue long-term solutions to rising healthcare costs, Medicaid agencies should not overlook one of the most immediate opportunities available: preventing avoidable improper payments before they occur.
Unknown Coverage Creates Significant Financial Leakage
Insurance coverage is constantly changing. Beneficiaries gain and lose commercial insurance throughout the year as employment, family status, and eligibility circumstances evolve. The challenge for Medicaid is that these changes often go unnoticed during claims adjudication.
A beneficiary may obtain employer-sponsored coverage, become eligible under a spouse's health plan, or transition between public and private coverage months before the information is fully reflected in Medicaid systems. During that period, claims continue to be processed using incomplete data. The result is avoidable spending that accumulates claim by claim, day after day, across large populations. For many programs, unknown commercial coverage is one of the largest barriers to effective coordination of benefits and accurate payments.
Prevention Produces Results Faster Than Recovery
Historically, many organizations have depended on post-payment recovery efforts to address improper payments. Once an issue is discovered, resources are devoted to identifying responsible parties, recovering funds, and correcting records. Although these activities remain necessary, they are inherently reactive. The better outcome is preventing the payment from occurring in the first place.
When accurate eligibility information and third-party liability data are available before adjudication, claims can be directed appropriately, ensuring Medicaid dollars remain in the program. This reduces administrative burden, improves operational efficiency, and strengthens payment accuracy at the point where it matters most. Preventing an improper payment eliminates the need to recover it later.
Why Data Quality Matters
Successful payment prevention depends on visibility. Medicaid programs can only coordinate benefits effectively when they have access to timely, accurate, and complete coverage information. Outdated records, delayed reporting, fragmented data sources, and incomplete eligibility information all contribute to payment decisions being made with an incomplete picture of beneficiary coverage.
Improving data quality enables agencies and managed care organizations to identify coverage earlier, verify eligibility more accurately, and make better payment decisions throughout the claims lifecycle. The impact extends far beyond any single claim category or service type.
A Comprehensive Approach to Cost Containment
Reducing healthcare costs and improving payment accuracy should not be viewed as competing priorities. Drug pricing initiatives, rebate programs, and purchasing reforms may help reduce Medicaid's payments for certain services and medications. At the same time, payment prevention strategies help ensure Medicaid pays only when it is the appropriate payer. Together, these approaches create a stronger foundation for program integrity. However, only one of them addresses the problem of claims being paid with incomplete eligibility information or unidentified third-party coverage. That is why prevention remains such a critical component of any cost-containment strategy.
The Opportunity Available Right Now
Large-scale policy reforms often require years of development, implementation, and evaluation before their full impact becomes clear. Payment prevention does not.
By improving eligibility accuracy, identifying unknown commercial coverage, strengthening third-party liability operations, and enhancing coordination of benefits processes, Medicaid programs can begin reducing avoidable expenditures immediately. The technology exists. The data sources exist. The operational frameworks exist.
The challenge is no longer whether prevention is possible. The challenge is ensuring Medicaid programs have the visibility necessary to make accurate payment decisions before claims are paid.
Drug pricing reform will remain an important component of Medicaid's long-term cost-containment strategy, but some of the most significant savings opportunities are already within reach. Programs that prioritize accurate eligibility data, early identification of third-party coverage, and proactive payment prevention can immediately reduce financial leakage, improve payment accuracy, and strengthen program integrity. Lower prices can reduce claim costs, but preventing Medicaid from paying claims that should have been covered elsewhere can preserve valuable program resources regardless of the claim's cost.
Monday, May 11, 2026
THIS MONTH IN MEDICAID – APRIL 2026
Syrtis Solutions shares a monthly Medicaid news brief that tracks the latest policy, research, and industry developments affecting Medicaid programs. Topics include program integrity, cost avoidance initiatives, coordination of benefits, improper payment reduction, and fraud, waste, and abuse oversight. The following section summarizes last month’s Medicaid news.
Tuesday, April 28, 2026
REDUCING IMPROPER MEDICAID PAYMENTS BEFORE THEY OCCUR
Stephen Konsin Jr. from Syrtis Solutions, a solution provider at the Marcus Evans Value-Based Care Summit 2026, discusses the growing need for proactive Medicaid payment accuracy and cost avoidance strategies.
Interview with: Stephen Konsin Jr., Vice President of Sales, Syrtis Solutions
“The window for demonstrating proactive prevention of improper payments before the 2030 mandatory Federal Medical Assistance Percentage (FMAP) reductions is narrowing with each fiscal quarter. Organizations that act now will be positioning themselves to meet federal compliance expectations while realizing multi-year operational benefits. Those that delay it will have limited time to demonstrate sustained improvement trends, reducing options for mitigating FMAP consequences,” says Stephen Konsin Jr., Vice President of Sales, Syrtis Solutions.
Syrtis Solutions is a solution provider at the Marcus Evans Value-Based Care Summit 2026.
What is changing with the One Big Beautiful Bill Act? What do healthcare leaders need to plan for?
The One Big Beautiful Bill Act (H.R. 1) converts improper payment performance from a compliance benchmark into a direct funding trigger. Beginning in FY2030, states will face mandatory FMAP reductions when Medicaid improper payment rates exceed three percent. This represents a paradigm shift from discretionary oversight to automatic financial penalties, with only limited waiver authority available to states demonstrating good-faith corrective action. FMAP reductions are triggered by error rates at adjudication, not by net financial impact after recovery efforts.
For healthcare organizations, unknown primary commercial insurance coverage represents a significant preventable category of improper Medicaid payments. When beneficiaries have unreported or recently activated commercial insurance, Medicaid systems lack real-time visibility at claim adjudication. Traditional third-party (TPL) liability infrastructure cannot close this gap. TPL programs mostly rely on member self-disclosure, delayed batch feeds, and periodic data matching that structurally miss coverage changes between verification cycles. What was improper at adjudication remains improper in Payment Error Rate Measurement (PERM) calculations regardless of later corrective action.
Why is the compliance clock ticking? What strategies could they implement to reduce improper payments before they occur?
We address this structural constraint through real-time access to nationwide commercial payer eligibility data. The platform verifies primary coverage by identifying previously unknown commercial insurance, enabling prevention before Medicaid payment occurs. This directly addresses the compliance metric triggering FMAP reductions. For Medicaid agencies and managed care organizations facing mandatory FMAP consequences, the compliance timeline is compressed. Organizations implementing real-time prevention capabilities now can demonstrate multi-year improvement trends before 2030 consequences take effect, thus creating the operational track record that limited waiver authority requires.
The FY2030 FMAP reduction mandate transforms prevention from operational “best practice” to fiscal imperative. States can no longer rely on recovery performance to manage TPL compliance. The PERM methodology measures error rates at adjudication, creating permanent advantages for prevention approaches that stop improper payments before they occur. Recovery programs remain necessary components of comprehensive TPL operations, addressing improper payments that evade prevention systems and managing historical claims. However, recovery alone cannot achieve FMAP compliance when error rates exceed three percent. Only prevention capabilities that reduce gross improper payment rates can protect federal medical assistance funds under the One Big Beautiful Bill Act requirements.
Why can’t traditional approaches solve this?
The fundamental constraint is data availability at the time of claims payment. The traditional pay-and-chase model is a rational response to ensure beneficiary access through prompt payment. However, this model cannot prevent FMAP reductions as it addresses errors after they occur.
Prospective prevention eliminates improper claims payments before occurrence by verifying coverage at payment decision and routing all future claims appropriately. A claim correctly routed to commercial insurance never appears as an improper Medicaid payment in PERM audits. It requires no identification, investigation, recovery or reconciliation. It creates no provider friction, member confusion or administrative burden. Cost avoidance is permanent and the improper payment never exists. This is not incremental improvement to recovery but a structural shift from retrospective correction to prospective prevention.
Does it work with their existing infrastructure?
Syrtis does not replace disclosed coverage already captured in eligibility systems, traditional carrier feeds or batch matching processes. It supplements existing infrastructure by addressing the specific gap those systems structurally cannot close. It identifies commercial coverage never disclosed to the state, coverage that changed since the last data match and coverage resulting from recent life events not yet in batch systems. Typical deployments reach full operational status within three months of project initiation, well within the window needed to begin building a measurable compliance track record before 2030 consequences take effect. The platform is designed to minimize implementation risk while maximizing operational resilience.
Any final thoughts?
In an environment where FMAP protection depends on preventing improper payments rather than recovering them afterward, the difference between prevention and recovery is the difference between maintaining federal matching funds and facing mandatory reductions compounding with every fiscal year.
Federal auditors will increasingly differentiate between programs that have embedded real-time prevention into operations versus those reliant on retrospective correction. The operational track record of implementing real-time verification in 2026, processing millions of claims over subsequent years, and identifying thousands of previously unknown commercial policies with measurable TPL-related improper rate declines presents a fundamentally different compliance profile than maintaining robust recovery while continuing payment without real-time verification.
Contact: Sarin Kouyoumdjian-Gurunlian, Press Manager, Marcus Evans, Summits Division, press@marcusevanscy.com
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About the Value-Based Care Summit 2026
The Value-Based Care Summit aims to foster innovative thinking, share inspiring ideas, and promote community connections. Our continuing mission is to curate an engaging program featuring visionary keynote presentations, real-life case studies and interactive forums delivered by compelling speakers and expert moderators. To achieve this vision we choose our collaborators with great precision – we seek out professionals who have deep expertise and hands-on experience, and can present cutting-edge insights that spark conversation.
About Syrtis Solutions
Syrtis Solutions was founded in 2011 after seeing payers of last resort – Medicaid, Medicare and Marketplace plans – struggle to properly identify third-party liability (TPL) information quickly and accurately. Still today, health plans rely on stale data mined from millions of other health insurance (OHI) coverage records that are incomplete, often expired, and frequently for the wrong member. This poor-quality data leads to member disruption and provider abrasion at the pharmacy counter, OHI overrides, and claims paid in error which fuels ineffective “pay and chase” recovery solutions – returning less than 17% of dollars attempted for recovery.
Today, we are helping solve this problem for health plans – looking for OHI on 42% of the Medicaid managed care lives covered by 83 different health plans. If you are looking for a better OHI discovery solution that reduces your reliance on “pay and chase” efforts – we invite you to meet with us. With as few as 5,000 member records, we can show you the opportunities you are missing and the quality of your current OHI data. Within just a few weeks, you will see your OHI cost avoidance efforts increase due to better quality OHI data, and we bet you will see less OHI override calls to your member services and pharmacy help desk as well!
About Marcus Evans Summits
Marcus Evans Summits are high level business forums for the world’s leading decision-makers to meet, learn and discuss strategies and solutions. Held at exclusive locations around the world, these events provide attendees with a unique opportunity to individually tailor their schedules of keynote presentations, case studies, roundtables and one-on-one business meetings. For more information, please visit www.marcusevans.com
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Monday, April 20, 2026
MEDICAID INDUSTRY UPDATE – MARCH 2026
Our monthly Medicaid news summary highlights important developments affecting Medicaid programs nationwide. The roundup focuses on research findings, regulatory changes, and policy discussions related to program integrity, cost avoidance, coordination of benefits, and efforts to address improper payments and fraud. Below is a recap of last month’s Medicaid headlines.
Wednesday, March 25, 2026
CLOSING THE GAPS: WHY FRAUD, WASTE, AND INEFFICIENCY CONTINUE TO DRAIN MEDICAID RESOURCES
Medicaid is one of the largest and most vital healthcare programs in the United States, serving millions of low-income individuals, seniors, and people with disabilities. As the program has expanded, so has the responsibility to ensure that every dollar is used appropriately. Yet despite ongoing oversight efforts, billions of dollars are lost each year to fraud, waste, and administrative inefficiencies—diverting critical funding away from patient care.
Fraud, defined as the intentional misuse of the program for financial gain, remains a visible and serious issue. Cases often involve providers billing for services that were never performed or overstating the level of care delivered. However, fraud represents only a fraction of the problem. The majority of improper payments stem from systemic and operational challenges—issues such as incomplete eligibility data, missing documentation, and gaps in coordination between Medicaid and other payers.
These challenges are structural. Medicaid operates in a constantly changing environment where beneficiary eligibility can shift rapidly due to income changes, employment status, or life events. At the same time, individuals may gain access to other forms of insurance that are not immediately reflected in Medicaid systems. When this information is not visible at the time a claim is processed, Medicaid may pay claims that should have been covered elsewhere or that do not meet program requirements.
The root of this issue lies in the disconnect between Medicaid’s modern-day complexity and its legacy infrastructure. Many of the program’s administrative processes were built decades ago, when enrollment was smaller, and data exchange was slower. Eligibility updates were periodic, data sharing was limited, and systems were not designed for real-time decision-making. While Medicaid has grown into a highly complex, multi-payer environment, much of its operational framework still relies on outdated approaches.
As a result, states often rely on eligibility and third-party liability data that is delayed or incomplete. Coverage information may lag behind real-world changes by weeks or even months, creating blind spots during claim adjudication. These blind spots are where improper payments occur—not necessarily because of intentional misuse, but because the system lacks the timely information needed to make accurate decisions.
The financial implications are significant. Improper payments reduce the pool of available resources, placing additional strain on state budgets and limiting the ability to invest in care delivery. Over time, this can impact the sustainability of key programs and services. At the same time, rising scrutiny from federal oversight agencies increases pressure on states to improve payment accuracy.
Traditional program integrity strategies have focused heavily on identifying and recovering improper payments after they occur. While audits and investigations remain important, they are inherently reactive. By the time an issue is identified, the funds have already been spent, and recovery efforts are often partial and resource-intensive.
A more effective approach focuses on preventing errors before they happen. By improving real-time visibility into eligibility and other coverage, Medicaid programs can ensure that claims are processed correctly from the outset. Modern data integration and real-time verification capabilities allow states to identify other available coverage, validate eligibility, and coordinate benefits more effectively—reducing reliance on post-payment corrections.
This shift from recovery to prevention represents a fundamental evolution in Medicaid program integrity. It not only protects financial resources but also reduces administrative burden and improves overall program efficiency.
Ultimately, addressing fraud, waste, abuse, and inefficiency is about ensuring that Medicaid can continue to meet the needs of the populations it serves. As the program continues to grow in scale and complexity, investing in real-time, data-driven solutions will be essential. Without that transformation, longstanding gaps will persist—allowing preventable losses to continue and limiting the program’s ability to deliver high-quality care where it is needed most.
Monday, March 16, 2026
MEDICAID INDUSTRY UPDATE – FEBRUARY 2026
To keep Medicaid professionals informed, Syrtis Solutions compiles a monthly overview of key Medicaid news. The report focuses on developments in program integrity, coordination of benefits, cost avoidance strategies, and ongoing efforts to reduce improper payments and fraud across the healthcare system. The following section summarizes last month’s news.
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