Aside from climbing health care costs and increased spending from the program's expansion, Medicaid is losing billions of dollars a year from improper payments. Protecting the integrity of the Medicaid program has become a top priority for the Centers for Medicare and Medicaid Services (CMS). CMS and individual states are looking to technology for cost avoidance solutions to protect the program from fraud, waste, and abuse.
T-MSIS
Earlier in the year, CMS and the US Comptroller General met with the Senate Homeland Security and Governmental Affairs Committee to go over the agencies initiatives to curb fraud, waste, and abuse. Administrator Verma testified and presented a variety of solutions geared toward audits, but in addition, she emphasized the importance of data optimization.
According to CMS, enhancing data will "drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP."
Verma went on to present the Transformed Medicaid Statistical Information System (T-MSIS). The system partners with states to implement advanced analytics and technologies in the collection of health services data. T-MSIS monitors submitted key information such as beneficiary eligibility, beneficiary and provider enrollment, service utilization, claims and managed care data, and expenditure data. This data will make it possible for states to operate more efficiently and reduce costs.
At the moment, states access federal databases for data matching and the identification of improper payments. However, the data is not current, available, complete, or accurate. While T-MSIS is still being developed and is years away from completion, Medicaid plans will continue to lose billions of dollars.
MAIS
Each state is required to pursue the recovery of erroneous payments but they lack the technology and data to do so. Rhode Island and Texas have resorted to technology to strengthen and improve their Medicaid programs. Both states have enrolled in the Medical Assistance Intercept System (MAIS).
States submit Medicaid recipient records into the MAIS database and they are then matched daily with personal injury and workers' compensation insurance claims. The system identifies and provides plans with matches and outreach services. States can then issue a lien to the insurer using the data from these matches. MAIS can also file with the insurers on the state's behalf. At the time of settlement, Medical claims are then collected by the state.
Rhode Island started employing MAIS in 2013 to intercept payments for reimbursement to it's Medicaid program. All insurance companies who do business in the state were required to participate in the program.
According to the state, "The MAIS program and Rhode Island's Executive Office of Health and Human Services (EOHHS) hit a new total of $25 Million in liens in April 2019. Achieving an exceptional increase of 25% since lien amounts were last reported [in September], MAIS has exceeded expectations and continues to grow in both scale and scope with a record single lien of $2.6 million."
This year, Texas became the second state to implement the MAIS program. It is using MAIS as a cost control initiative and expects to offset medical assistance costs in the state.
ProTPL
Outside of government-sponsored programs, there are a number of recovery services; however, none of them effectively reduce improper payments. More than a decade ago, Syrtis Solutions recognized the need for cost avoidance in the Medicaid program and created ProTPL, a real-time, prospective TPL solution for payers of last resort.
Formerly, plans would attempt to maintain data of each beneficiary to coordinate claims correctly. The constant flux of member eligibility, the complexity of coordinating benefits (COB), and the lack of quality data made this extremely challenging. The result was that claims were regularly paid in error and plans had to turn to 'pay and chase' to recover funds. The recovery efforts of these improper payments were also very costly.
The ProTPL program minimizes the need for post-payment recovery with accurate, useful, and real-time ePrescribing eligibility data. The tool seamlessly integrates into Medicaid plans existing processes and immediately decreases improper claims and the need for 'pay and chase.'
Lawmakers, government agencies, and plan administrators are focused on protecting the integrity of the Medicaid program and are turning to technology solutions to do so. Even though recovery efforts are necessary, Medicaid plans recognize that cost avoidance makes more sense. The technology needed to successfully cost avoid is now available from Syrtis Solutions.
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