JANUARY MEDICAID PROGRAM INTEGRITY SNAPSHOT

 

Syrtis Solutions’ monthly Medicaid mailer provides a focused look at the policy and operational changes influencing payment accuracy and program integrity. Below is a snapshot of notable Medicaid developments from the last month.

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ADDRESSING MEDICAID BUDGET PRESSURE WITHOUT REDUCING BENEFITS

As states prepare their fiscal year (FY) 2027 Medicaid budgets, financial flexibility is becoming increasingly limited. State revenue growth has slowed, health care costs continue to climb, and federal policy changes enacted through the 2025 budget reconciliation law have altered how future funding risk is managed. Even as enrollment stabilizes, Medicaid spending remains on an upward trajectory, driven by higher clinical complexity, increased utilization of long-term services and supports, rising pharmacy expenditures, and expanded behavioral health needs.

In this environment, states are revisiting familiar cost-containment strategies. Proposals to reduce provider reimbursement, narrow optional benefits, or tighten utilization controls are once again entering budget conversations. While these measures can reduce spending in the short term, they often introduce downstream challenges—including access limitations, provider participation concerns, and outcomes that conflict with CMS’s emphasis on coverage stability and care quality. As financial pressure grows, Medicaid agencies and managed care organizations (MCOs) are increasingly seeking alternatives that protect budgets without undermining benefits.

Improper Payments Now Carry Direct Budget Risk

One of the most significant shifts affecting Medicaid finances is the heightened consequence of payment errors. Improper payments above the federal 3 percent threshold now result in concrete funding penalties, regardless of whether states later recover the dollars. Federal matching funds may be reduced for any excess over the benchmark, with fewer opportunities for exceptions or mitigation.

This framework fundamentally changes the role of recovery. Post-payment collections no longer shield states from financial exposure or help preserve future funding. A payment made incorrectly remains improper under federal standards—even if it is later recouped—making prevention the only reliable way to manage risk.

Moving Beyond “Pay and Chase”

A large portion of Medicaid improper payments occur when claims should have been paid by another insurer. Traditional recovery-based approaches identify these issues only after funds have been disbursed, offering little benefit in reducing improper payment rates.

Prospective cost avoidance addresses this challenge by stopping errors before they occur. Real-time identification of other health insurance and third-party liability ensures Medicaid consistently acts as the payer of last resort. Each avoided improper payment directly supports compliance with the 3 percent standard and preserves funding for covered services.

Operational Accuracy Drives Financial Stability

Administrative inefficiencies often compound budget challenges. Manual claims review, fragmented eligibility systems, and delayed coverage verification increase error rates while adding operational cost.

By automating eligibility checks, coverage validation, and claims workflows, Medicaid programs and MCOs can improve accuracy while reducing administrative burden. Operational modernization enables compliance with federal standards without shifting costs onto providers or beneficiaries.

Program Integrity as a Budget Strategy

Program integrity has become a central component of fiscal management rather than a retrospective compliance exercise. Continuous monitoring, data-driven oversight, and early risk detection allow states to prevent recurring payment issues before they escalate.

When paired with prospective cost avoidance, these efforts reduce financial leakage, improve audit preparedness, and support long-term budget sustainability—even during periods of economic uncertainty.

Protecting Coverage Through Prevention

As Medicaid budgets face increasing pressure, benefit reductions should remain a last-resort option. The most effective way to prepare for funding constraints is to ensure claims are paid correctly the first time.

Preventing improper payments, maintaining compliance with the federal 3 percent standard, and modernizing operational processes allow states and MCOs to preserve access to care while safeguarding limited resources. In today’s Medicaid environment, cost avoidance is not optional—it is essential to sustaining program integrity and financial stability.

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MEDICAID 2025: LEGISLATION, INNOVATION, AND OVERSIGHT

Syrtis Solutions’ year-end Medicaid recap provides a clear snapshot of 2025’s most significant developments. Topics include program integrity, coordination of benefits, third-party liability, and efforts to combat fraud, waste, and abuse.

Read more here. 

KEY MEDICAID NEWS – DECEMBER 2025 RECAP

 

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.

Learn more here. 

MEDICAID UPDATES & HIGHLIGHTS – NOVEMBER 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.

Click here to find out more. 

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.