Syrtis Solutions distributes a monthly Medicaid news digest designed to keep policymakers and healthcare leaders informed. The summary highlights key developments in Medicaid program integrity, coordination of benefits, cost avoidance, and efforts to prevent improper payments, fraud, waste, and abuse. Below is a summary of last month’s news.
Automated algorithmic analysis and insurance discovery engines (AAAIDE) are becoming cornerstones of modern Medicaid operations. By identifying liable third-party coverage at the point of claim adjudication, these technologies reduce improper payments, strengthen payment accuracy, and improve coordination of benefits.
This priority is now reflected in state policy. On June 10, 2026, Ohio passed Senate Bill 315, which requires the Ohio Department of Medicaid to use automated algorithmic analysis and insurance discovery engines before making any Medicaid payment. The measure reflects a broader regulatory shift toward prevention over post-payment recovery.
Under the One Big Beautiful Bill Act (HR1), states must maintain improper payment rates below 3% by federal fiscal year 2030, measured through PERM audits that flag claims where Medicaid was billed as primary despite active third-party coverage. Critically, PERM audits measure compliance at the point of adjudication: once a claim is paid improperly, recovery cannot reverse the improper payment designation. Only point-of-claim insurance discovery prevents both the improper payment and the HR1 compliance risk simultaneously. Traditional post-payment recovery addresses cost but not compliance.
Long before this legislative requirement, Syrtis Solutions was delivering these capabilities to Medicaid managed care organizations nationwide. ProTPL, Syrtis' proprietary platform, continuously analyzes claim-level eligibility and coverage data to identify active commercial insurance, Medicare, and other liable third-party coverage at the point of adjudication, surfacing coverage that traditional monthly or quarterly eligibility files miss entirely.
This point-of-claim approach improves coordination of benefits, supports cost avoidance initiatives, and directly addresses PERM audit compliance. As Medicaid programs face HR1 improper payment standards and deadline pressure, real-time insurance discovery has become essential to compliance strategy.
About Syrtis Solutions: Syrtis Solutions provides insurance discovery, coordination of benefits, and payment integrity solutions for Medicaid agencies and Medicaid managed care organizations. Through ProTPL, Syrtis helps clients identify previously unknown commercial coverage, optimize third-party liability routing, and support PERM compliance while helping clients meet Medicaid's payer-of-last-resort requirements.
For more information, contact: Steve Konsin, Jr. 866-960-9358 info@syrtissolutions.com www.syrtissolutions.com
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.
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.
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.
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.
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.
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.
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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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.
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!
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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.
