SEPTEMBER MEDICAID NEWS

Syrtis Solutions issues a monthly Medicaid news roundup to help you stay informed. The monthly recap focuses on developments, research, and legislation that relates to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a list of last month's Medicaid news.

Open September's news here. 

MEDICAID TPL SOLUTION PRESENTS A CONSIDERABLE SAVINGS OPPORTUNITY

 

Dependence on the Medicaid program has increased exponentially over time. Currently, it is the single largest insurer in the country, and in FY 2019, it accounted for more than half of all federal monies distributed to states. Regrettably, as the safety net program has grown, waste has also become more widespread. Improper payments are costing the program billions of dollars every year.

Despite being on the GAO's High Risk List since 2003, Medicaid's improper payment rate continues to surge and put more pressure on budgets. In 2018, the program's improper payment rate was at nine percent, and by 2020 it had grown to twenty-one percent. That equates to a shocking $143 billion. However, according to analysts, these numbers are conservative estimates that do not take into account all the needed data. In reality, the improper payment rate is thought to be closer to twenty-seven percent or $100 billion annually.

Initiatives to Decrease Improper Payments

Fiscal integrity has been a problem for Medicaid since its conception. So much so that over the last 56 years, various policy and legislative efforts have occurred to focus on improper payments. These efforts primarily evaluate the risk of fraud, estimate the effect of TPL, increase reporting requirements, and increase data sharing. Unfortunately, while these actions help bring the problem into scope, they do nothing to prevent the improper payment rate from climbing.

Apart from these legislative efforts to manage costs, some policymakers have suggested transforming how the safety net program is funded to decrease waste. They think that the program should be incentivized to use funding more responsibly and efficiently. One thought is to implement block grants. These grants would take into consideration the size of the eligible population within a state and give the states the flexibility to distribute the funds with limited oversight from the federal government. The states would be responsible for ensuring that the appropriate care is being delivered to beneficiaries and that program resources are not wasted. Another idea is for Congress to establish tax-free health savings accounts to lessen the dependence on Medicaid and improve access to health care for those in need. The accounts would be financed with the savings achieved from decreasing waste in the Medicaid program.

Reducing Improper Payments with Medicaid TPL Tech Solutions

While lawmakers think about program reform, one area of opportunity to dramatically reduce costs lies within Medicaid's coordination of benefits. Currently, the majority of Medicaid's improper payments actually stem from bad quality data and inefficient TPL processes, not deliberate fraud and abuse. Payers of last resort struggle to identify primary coverage on pharmacy and medical claims. Much of the data they have access to is not current, available, complete, or accurate. Consequently, plans have no choice but to pay claims in error and chase reimbursement once other health insurance (OHI) is found. Unfortunately, the actual funds recovered are around twenty cents on the dollar.

Syrtis Solutions realized that Medicaid plans needed a way to identify active OHI coverage so that claims could be adjudicated properly. In 2010, they introduced ProTPL, a real-time point of sale cost avoidance service for the payer of last resort market. ProTPL supplies powerful and accurate eligibility data that can be acted upon. The solution gives plans the ability to cost avoid pharmacy and medical claims and the associated costs of recovery. Additionally, the coverage identified by ProTPL can not be found by other vendors. Syrtis Solutions is able to do this by checking claims against the nation's largest and most complete active healthcare coverage information database. Customers who implement the tool see an average 25% increase in OHI discovery. This means Syrtis' customers get the best and latest eligibility responses when they need them.

In March, enrollment in the Medicaid program reached nearly 75 million people, and that number continues to rise. As a result, the chances for waste and improper payments are likely to increase also. This is problematic considering that Medicaid is losing billions every year in improper payments already. Due to strained budgets, program integrity issues, and enrollment surges, some policymakers and states are considering innovative ideas and program reform to reign in costs and decrease waste. While these efforts are being considered, they have yet to be implemented. At this time, one of the most significant opportunities for reducing Medicaid's improper payments lies within the coordination of benefits. Plan administrators should turn to TPL technology solutions for further efficiency and cost avoidance opportunities.

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AUGUST MEDICAID NEWS RECAP

 

Syrtis Solutions distributes a monthly Medicaid news recap to help you stay up-to-date. The monthly summary highlights developments, analysis, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, improper payments, fraud, waste, and abuse. Below is a summary of last month's notable Medicaid articles.

Click this link to open the news.