ADDRESSING IMPROPER PAYMENTS WITH A DATA-DRIVEN SOLUTION

 

The reported government-wide improper payment rate of 3.97% in 2024 represents the lowest level in over ten years. But below the surface lies a complicated reality that exposes systemic flaws in how improper payments are measured and controlled. These numbers, far from representing legitimate progress, highlight the important need for significant reform and solutions.

What Exactly Is The Improper Payment Rate?

Improper payment rates are often used as a headline metric to signal success or failure. Yet these rates, calculated as a percentage of total spending, tell only a part of the story. A declining rate does not always mean less improper payments; it could simply reflect a surge in spending that outpaces the growth of improper payments. For example, out of the 46 federal programs with consistent data for 2023 and 2024, only about half announced a reduction in improper payment rates. That being said, the picture changes when looking at the actual dollar amounts: two-thirds of these programs revealed increased improper payment totals. Some programs spent more but managed to mask these increases with lower rates, while others spent less and still saw improper payments rise. This disconnect highlights the limitations of relying on percentages alone.

Medicaid's Billion Dollar Problem

Medicaid's improper payment rate illustrates these difficulties well. In 2023, the program reported a rate of 8.6%, a figure already considered underestimated because of relaxed eligibility requirements during the COVID-19 pandemic. These policies temporarily reduced review, skewing the numbers.

By 2024, Medicaid's improper payment rate dropped drastically to 5.09%. However, this reduction had less to do with actual improvements and more with the methodology used by the Department of Health and Human Services. Medicaid calculates its improper payment rate using a rolling three-year average, meaning the impacts of temporary COVID-19 policies will continue to distort the numbers until at least 2025.

Addressing Medicaid's Improper Payments

To protect Medicaid from improper payments, several legislative initiatives have been made. While these steps have helped identify and report improper payments, they have done little to reduce them. Consequently, agencies expend substantial resources on reporting requirements that do little to address the root causes of improper payments. This process-driven mindset diverts attention from proactive, data-driven solutions that could make a real difference. Moreover, the repercussions of improper payments extend beyond mere monetary loss. They hinder access to quality care for beneficiaries, diverting resources from legitimate medical services and interventions. Patients may encounter barriers to receiving necessary treatments, while providers face increased scrutiny and regulatory burdens. Moreover, the broader healthcare system bears the brunt of these inefficiencies, grappling with rising costs and diminished effectiveness.

One of the most effective data-driven solutions for combating Medicaid's improper payments has emerged from the private sector. Syrtis Solutions ( Syrtis) has introduced a technology-based solution to aid the program in detecting third party liability (TPL) before medical and pharmacy claims are paid improperly. Syrtis discovered that Medicaid's conventional TPL discovery processes' are primarily retrospective and fail to capture 13.4% of individuals who have unreported primary commercial coverage. Because of this, Medicaid loses billions in improper claims payments; consequently, inefficient post-payment recovery processes are used to recoup the improper payments. To make matters worse, these post-payment recovery efforts only recoup less than $0.20 on the dollar. With the help of Syrtis Solutions and their proprietary ePrescribing data, Medicaid plans are now able to cost avoid pharmacy and medical claims on the front end and significantly reduce improper payments.

A Smarter Way Forward

Improper payments are costing Medicaid and other programs billions of dollars annually. By adopting data-driven solutions, federal government programs can move from compliance-focused reporting processes to proactive strategies that improve efficiency and integrity. This approach will help streamline operations, ensure accountability, and strengthen public trust in the government's ability to safeguard taxpayer funds.

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NOVEMBER MEDICAID ROUNDUP

 

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

Read the news. 

MEDICAID PAYMENT INTEGRITY: ADDRESSING IMPROPER PAYMENTS

 

Improper payments and fraud continue to be chronic and costly difficulties for Medicaid and other government-funded programs. The GAO defines improper payments as payments that should not have been made or that were made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. According to the GAO, the federal government loses between $233 billion and $521 billion annually to fraud alone.

Since FY 2003, executive branch agencies have reported increasing improper payment estimates totaling approximately $2.7 trillion. In fiscal year 2023 alone, federal agencies reported $236 billion in improper payments across 71 programs. While the FY 2023 estimate represents an $11 billion downturn from the previous year, this reduction is credited to temporary flexibilities granted during the COVID-19 PHE. These measures, such as relaxed eligibility requirements for Medicaid beneficiaries and providers, minimized instances of improper payments under the altered criteria.

Medicaid's High-Risk Status

Medicaid has been on the GAO's High-Risk List since 2003 due to vulnerabilities in payment integrity. In FY 2023 alone, HHS estimated that Medicaid improper payments totaled $50 billion. According to HHS, the leading contributors to these payments are missing or insufficient documentation, particularly in validating beneficiary eligibility and payments to ineligible beneficiaries or ineligible services.

Actions and Legislative Efforts to Reduce Improper Payments:

CMS has made some progress in identifying these susceptibilities. For instance, CMS collaborated with states and audit contractors to improve oversight of healthcare companies contracted to manage healthcare services for Medicaid beneficiaries. Investigations rose from 16 between 2016 and 2018 to 893 between 2019 and 2021, uncovering significant overpayments.

Over time, several legislative efforts have been aimed at curbing fraud, waste, and abuse. Despite these pieces of legislation, Medicaid continues to lose billions of dollars because of payments made in error. The measures directed by the legislation are costly and primarily revolve around compliance and reporting rather than reducing improper payments.

Remaining Challenges:

The GAO identified several areas for improvement, including:

Provider Screening and Enrollment Requirements

The GAO suggested CMS review state compliance with screening and enrollment requirements and monitor noncompliance yearly. While CMS has provided technical assistance, further action is needed to assess and address all states' compliance.

Medical Reviews for Improper Payments

The GAO advised CMS to strengthen Medicaid's medical review processes to identify the root causes of improper payments and implement corrective actions. As of March 2024, HHS disagreed with this recommendation and does not plan to implement it.

Compliance with the Payment Integrity Information Act of 2019 

Medicaid was deemed compliant with PIIA criteria in FY 2023. However, it was not fully compliant in fiscal years 2021 and 2022.


Considerable gaps remain in addressing improper payments and fraud. By fully implementing GAO recommendations and enhancing oversight, federal agencies and programs like Medicaid can better safeguard taxpayer dollars, reduce waste, and improve operational efficiency. Nevertheless, to prevent improper payment rates from rising even more, agencies should look to innovate data solutions to identify and prevent fraud, waste, and abuse.

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MEDICAID NEWS IN OCTOBER

 

Syrtis Solutions distributes a monthly Medicaid news summary to help you stay informed. The monthly summary concentrates on developments, analysis, and legislation that pertains to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's important Medicaid news.

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ACAP RECOGNIZES SYRTIS SOLUTIONS AS A PREFERRED VENDOR

Syrtis Solutions, a leading provider of real-time Other Health Insurance (OHI) coverage information for payers of last resort, just recently accomplished a significant milestone by being identified as a preferred vendor for the Association for Community Affiliated Plans (ACAP). This designation is a reflection of Syrtis Solutions' commitment to decreasing costs and improving operational efficiency for government-funded health plans.

The Significance of Cost Avoidance in Medicaid

The Medicaid landscape is complex and continually evolving, with state and federal guidelines mandating strict cost-control measures to protect the program's sustainability. One of the fundamental methods for managing costs in Medicaid programs is avoiding improper claims payments, which involves identifying third-party liability (TPL) and ensuring that Medicaid is the payer of last resort.

Without effective cost avoidance tools, Medicaid programs can suffer from unnecessary expenditures, driving up costs and redirecting resources away from other vital healthcare needs. This is where Syrtis Solutions has been making a significant impact.

Syrtis Solutions: Pioneers in Real-Time Cost Avoidance

Founded in 2008, Syrtis Solutions has been at the forefront of developing innovative solutions to deal with the challenges of OHI identification and cost avoidance. Their flagship product, ProTPL, is a real-time pharmacy cost avoidance solution that provides Medicaid and other government-funded health plans with immediate access to actionable data. By quickly identifying whether a member has other insurance coverage, ProTPL helps plans avoid paying for claims that should be covered by a liable third-party payer. This not only helps Medicaid plans comply with federal regulations but also significantly reduces the time and effort required to manually identify third-party insurers and recover costs retroactively.

What It Means To Be An ACAP Preferred Vendor

ACAP is a national trade association that represents 78 nonprofit Safety Net Health Plans, covering more than 25 million individuals through Medicaid, Medicare, and other public health programs. ACAP's Preferred Vendor program is designed to spotlight companies that offer valuable services to member health plans and have a proven track record of improving the quality and efficiency of care.

By becoming an ACAP Preferred Vendor, Syrtis Solutions has joined an elite group of companies that have exhibited a strong commitment to serving community health plans. This designation demonstrates Syrtis Solutions' expertise and reliability in the Medicaid space, as well as its dedication to helping ACAP member plans improve cost-avoidance efforts.

Looking Ahead

As healthcare costs continue to increase and Medicaid plans face increasing pressure to control expenditures, the role of payment integrity will only grow in importance. With its newly cemented status as an ACAP Preferred Vendor, Syrtis Solutions is well-positioned to help all payers of last resort maneuver these challenges, making certain that limited healthcare dollars are used efficiently and effectively.

Syrtis Solutions' innovative real-time cost avoidance technology, combined with its proven expertise, offers an essential resource for Medicaid plans seeking to enhance their operational efficiency and reduce unnecessary spending. This partnership marks a significant step forward in improving Medicaid cost management and patient care across the country.

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SEPTEMBER MEDICAID NEWS ROUNDUP

 

Syrtis Solutions publishes a monthly Medicaid news recap to help you stay informed. The monthly summary highlights 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 summary of last month's important Medicaid news.

Read here. 

AUGUST MEDICAID NEWS RECAP

 

Syrtis Solutions sends out a monthly Medicaid news summary to help you stay up-to-date. The monthly summary concentrates on developments, research, and legislation that pertains 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 important Medicaid news.

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INSURERS FACE FINANCIAL STRAIN FROM MEDICAID ENROLLMENT CHANGES

 

Throughout the COVID-19 pandemic, Medicaid enrollment surged because of federal measures that required states to maintain coverage for individuals, regardless of whether they gained other insurance. This policy, implemented in March 2020, lasted three years and added over 23.3 million people to the Medicaid program, pushing the total number of beneficiaries to 95 million at its peak. Private insurers managing Medicaid plans greatly benefited from this influx, as roughly 75% of Medicaid enrollees were under their care. That being said, with the end of the public health emergency, states have started removing individuals from Medicaid, resulting in more than 20 million people being disenrolled over the past year.

This decline in members has resulted in a significant decrease in revenue for insurers. While the reduction in revenue was expected, the greater concern for insurers has been the shift in the demographic of remaining enrollees. As healthier individuals left Medicaid roles, those who remained tended to have higher healthcare costs. This unexpected trend has put pressure on insurers' earnings, with companies like Centene, Elevance, and UnitedHealth experiencing increased Medicaid expenses this year.

In some cases, many disenrolled individuals had other coverage, including employer-sponsored plans, but were still being counted as Medicaid members. Some were even unaware of their continued Medicaid enrollment during the pandemic, further inflating the numbers of people who weren't utilizing Medicaid services, yet still generating payments for insurers. This dynamic created a windfall for insurance companies, who were receiving funds from states for program members who didn't access care.

The effect of these changes is being felt in the stock market. For example, Elevance's shares dropped when the company forecasted higher Medicaid costs in the latter half of the year. Molina, however, experienced a positive trading response after reporting earnings that offset Medicaid-related pressures with other financial gains.

Medicaid businesses already operate on thin profit margins, and higher utilization rates exacerbate their financial challenges. Though insurers are working to secure better rates from states to account for rising costs, the process is slow because of the decentralized nature of Medicaid, where each state establishes rates individually. Although eventual rate adjustments are anticipated to reduce some of the pressure, the road ahead for Medicaid insurers remains uncertain and challenging as they navigate this transitional Medicaid enrollment period. In order to conserve program resources, insurers must look to innovative ways to increase efficiency and reduce costs.

Discover more here. 

MEDI-CAL: GROWTH, EXPANSION, AND IMPACT

 

Over the past three decades, Medi-Cal, California's Medicaid program, has undergone considerable changes and expansion. By 2016, the program provided coverage to more than one in three Californians, and as of January 2024, eligibility has been extended to include all residents with incomes below certain thresholds.

In 1990, Medi-Cal served about one in eight Californians, with eligibility limited to specific low-income groups like children, parents or caretakers of dependent children, and people with disabilities. Enrollment increased gradually throughout the 1990s and 2000s, influenced by economic shifts and minor expansions in eligibility for children and pregnant women. The ACA brought a significant change in 2014, allowing states to extend Medicaid coverage to most low-income adults without children or disabilities, with the federal government covering the majority of the costs. This brought about a more than 60% increase in Medi-Cal enrollment by 2016, adding over 5 million Californians to the program. At present, 46% of Medi-Cal enrollees are children and their caregivers, 34% are adults who gained coverage through the ACA, and around 15% are seniors and individuals with disabilities. Since the ACA expansion, the number of uninsured Californians has been reduced by half, with improvements noted in various health and economic areas. However, nearly 3 million state residents remain without comprehensive health insurance, many of whom are noncitizens excluded by federal policies. California has taken steps to address this gap.

As the state with the largest immigrant population, California has worked to close eligibility gaps created by federal restrictions and requirements on Medicaid access for some immigrants. When welfare reform in the 1990s separated Medi-Cal from cash assistance and limited eligibility to documented immigrants with green cards for at least five years, California chose to cover these individuals before they reached the five-year mark. Also, California extended coverage to several groups of low-income immigrants, including those with Deferred Action for Childhood Arrivals (DACA) status.

In the last few years, California has steadily expanded Medi-Cal eligibility, beginning with undocumented children. This was followed by expansions to include undocumented young adults, older adults, and, as of January 2024, all remaining adults who meet the income criteria.

Medi-Cal's massive expansion has made it the largest single expenditure in California's state budget, with total costs projected to approach $160 billion this fiscal year. This includes $98 billion in federal funds, $36 billion from the state General Fund, and $25 billion from other sources, including local governments and provider taxes such as the Managed Care Organization (MCO) Tax. The MCO tax was increased in both 2023 and 2024, with some of the revenue intended to raise payment rates for Medi-Cal providers to enhance access to care-- an ongoing priority for healthcare stakeholders. However, concerns about the state budget have put this plan in jeopardy. In November, voters will decide whether the revenue from the MCO tax should be committed to increasing provider rates or if more of it should be used to balance the state budget.

Medi-Cal has been at the forefront of Medicaid expansion, and research indicates that this growth has resulted in better insurance coverage, improved health outcomes, and a reduction in poverty. As the program continues to be a lifeline for millions, preserving and responsibly managing its resources is necessary. One effective approach is for plans administering the program to make use of modern technology solutions to enhance the coordination of care, improving efficiency and reducing costs. By maintaining and strengthening this vital program, California can continue to provide critical healthcare services to its most vulnerable residents.

Discover more here. 

JULY MEDICAID RECAP

 

Syrtis Solutions delivers a monthly Medicaid news summary to help you stay informed. The monthly summary highlights 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 significant Medicaid developments.

See the news. 

Proposition 35: A Tax on Managed Care Organizations

 

Proposition 35 is a proposed ballot measure in California that aims to enforce a fixed tax on managed care organizations (MCOs) that provide healthcare services for Medi-Cal. The measure also outlines specific ways the tax revenue must be utilized.

Background

Proposition 35 comes amid recent expansions to California's Medicaid program, Medi-Cal. Lawmakers have expanded Medi-Cal eligibility to include individuals who meet income requirements despite immigration status. Despite this expansion, many healthcare providers and advocacy groups claim that reimbursement rates under Medi-Cal are inadequate to cover the cost of care. Proposition 35 aims to address this funding shortfall.

What is the MCO Tax?

California has historically implemented an MCO tax periodically. In the summer of 2023, Governor Gavin Newsom and state legislators renewed this tax to support Medi-Cal, particularly as more residents became eligible for Medi-Cal coverage. According to the Legislative Analyst's Office, the tax is projected to generate between $6 billion and $9 billion annually through 2026.

Initially, lawmakers agreed to use part of the tax revenue to increase the reimbursement rates for providers serving Medi-Cal patients. These increases were viewed as necessary to avoid provider shortages and long wait times for patients. However, Governor Newsom later proposed reallocating billions from the MCO tax to pay for other Medi-Cal expenses. Consequently, the agreed-upon budget included funds for Medi-Cal provider rate increases, although less than initially planned.

Key Provisions of Proposition 35

Proposition 35 seeks to clearly define the allocation of MCO tax revenue. It limits California lawmakers' power to redirect these funds for other purposes, requiring a supermajority—three-quarters of the members—from both the state Assembly and Senate to make any changes to the measure in the future.

The proposition also proposes creating a new advisory committee for the Department of Health Care Services. This committee would include people from various sectors of the healthcare industry, such as physicians, hospitals, clinics, labor unions, and other healthcare stakeholders, to steer the allocation of tax revenue.

Allocation of Funds

In the short term, Proposition 35 mandates that the tax revenue be allocated as initially planned before Governor Newsom's proposed reallocations. This includes:

• Increasing reimbursement rates for healthcare providers under Medi-Cal.
• Funding training programs for healthcare workers.
• Supporting Medi-Cal costs from the state's general fund, which finances most public services.

The measure establishes a formula for distributing funds to different programs starting in 2027, with allocations contingent on the revenue generated by the tax.

Support and Financial Backing for Proposition 35

The Coalition to Protect Access to Care, a group comprising various healthcare organizations and associations, along with the California Democratic Party and the California Republican Party, have endorsed the measure. As of now, no organized opposition committees have been identified.

Additionally, significant financial contributions have been made to support Proposition 35, largely from healthcare industry groups:

• Global Medical Response Inc. has donated $5 million.
• California Hospitals Committee on Issues, sponsored by the California Association of Hospitals and Health Systems, contributed $2 million.
• The California Medical Association has provided $3.2 million.

Financial Ramifications

The Legislative Analyst's Office noted that Proposition 35 might reduce legislators' flexibility in overseeing the state budget. According to reports, Governor Newsom urged the coalition backing the measure to remove it from the ballot. The state's current budget relies on revenue from the MCO tax, and passing Proposition 35 could interfere with existing budgetary plans, according to arrangements in the health budget bill.

Discover more here. 

JUNE MEDICAID RECAP

 
Syrtis Solutions delivers a monthly Medicaid news roundup to help you stay up-to-date. The monthly roundup focuses on developments, analysis, and legislation that pertains 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 important Medicaid developments.

View last month's news here. 

STRENGTHENING PAYMENT INTEGRITY AND REDUCING ABRASION

 

Payment integrity programs are developed to provide correct claims processing, adherence to contractual rates, and compliance with payment rules. These efforts are essential for maintaining the financial stability of healthcare systems and making certain that patients receive appropriate care. That being said, they can produce friction between payers and providers, originating from disputes over claim denials, decreased reimbursements, and the administrative burden associated with claims adjudication.

Providers are under considerable pressure, with inflation at 3.3% driving up hospital costs. Additionally, cuts to Medicare physician payment rates are making it more and more challenging for physicians to maintain their practices, adding to a rise in hospital-employed physicians, now at 77.6%, a 25.8% increase from a decade ago.

Compounding these challenges, 7% of physicians have left the workforce, mainly from internal medicine and family practice. Healthcare organizations must find ways to compensate for these shortages, with increased billing on claims being one potential method to recoup costs. Unfortunately, this can increase tensions between payers and providers.

As payment integrity becomes more important due to rising healthcare spending and complex billing processes, it must focus on reducing provider abrasion to improve billing practices and relationships between health plans and providers.

Improving communication around claim denials and payment policies is one primary method to reduce provider abrasion. Readily available policies can reduce the chances of surprises by helping providers know what to expect when processing claims.

The next important strategy is communication coupled with the human element. While the role of artificial intelligence (AI) in healthcare is a hot topic at the moment, it will take some time for technology to fully comprehend the complexity of medicine and coding. Codes and rules are constantly changing and being added. Payment integrity requires human expertise and interactions to effectively address provider abrasion. AI is unable to explain complex payment integrity decisions like clinicians with extensive coding knowledge and coders with deep clinical knowledge.

Another effective approach is tailoring payment integrity solutions to meet the unique needs of various providers and patient populations. Sometimes, a payer might allow claims from a specific provider offering advanced treatment considered investigational that might not be allowed from another provider. It's important for payer organizations to handle such situations in a custom manner.

One more vital component of payment integrity programs is the adoption of modern technology solutions that utilize accurate and usable eligibility data in coordinating benefits. When Medicaid payers do not have access to clean eligibility data, it can lead to abrasion at the pharmacy for program beneficiaries and lead to improper payments. Accurate eligibility data significantly helps to properly adjudicate claims, saves valuable program resources, and, most importantly, ensures that members receive the care and medications they need.

Clear communication, human expertise, and customized solutions are key to enhancing the relationship between healthcare providers and payer organizations. The adoption of modern technology solutions and clean, actionable data is another key tool for reducing abrasion and honing payment integrity. As the healthcare industry evolves, these strategies and data solutions will ensure efficient payment integrity efforts, ultimately leading to better patient outcomes.

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MAY MEDICAID NEWS ROUNDUP

 

Syrtis Solutions issues a monthly Medicaid news recap to help you stay up-to-date. The monthly recap focuses on developments, research, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's important Medicaid news.

Discover more. 

APRIL MEDICAID RECAP

 

Syrtis Solutions issues a monthly Medicaid news summary to help you stay informed. The monthly summary concentrates on developments, research, and legislation that pertains to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's important Medicaid news.

Learn more here. 

IMPROPER PAYMENTS THREATEN MEDICAID AND MEDICARE

America's most vulnerable populations turn to Medicaid and Medicare for essential healthcare services. Regrettably, these programs lose billions of dollars annually as a result of improper payments. Just recently, the Subcommittee on Oversight and Investigations delved into this pressing issue in a pivotal hearing titled "Examining How Improper Payments Cost Taxpayers Billions and Weaken Medicare and Medicaid." The discoveries shed light on the far-reaching effects of these errors and highlighted the urgent need for reform.

At the heart of the hearing was an exploration of the extent and impact of improper payments within Medicare and Medicaid. These erroneous disbursements, whether stemming from fraud, waste, or abuse, represent a substantial strain on public resources, amounting to billions of dollars annually. This sort of waste not only erodes the fiscal integrity of these critical healthcare programs but also undermines their ability to fulfill their mission of providing crucial medical services to vulnerable populations.

The subcommittee's inquiry revealed a complex landscape of improper payments, with fraudulent activities and administrative errors adding to the problem. Fraudulent schemes, such as billing for services not rendered or inflating claims through deceptive practices, exploit vulnerabilities within the system, leading to substantial financial losses. Furthermore, administrative inefficiencies, outdated technology, and bad-quality data intensify the issue, hindering accurate eligibility determinations and claims processing.

The effects of improper payments extend beyond mere monetary loss. They disrupt access to quality care for beneficiaries, diverting resources away from legitimate medical services and interventions. Beneficiaries may encounter barriers to receiving needed treatments, while providers face increased scrutiny and regulatory burdens. Moreover, the broader healthcare system bears the brunt of these inefficiencies, grappling with rising costs and diminished effectiveness.

The hearing also highlighted the significance of proactive measures to combat improper payments and strengthen the integrity of Medicare and Medicaid. Enhanced oversight, quality data and analytics, and targeted reforms were among the proposed strategies to reduce fraud and waste. By leveraging technology solutions and promoting collaboration among government agencies and healthcare providers, policymakers aim to identify and prevent improper payments more successfully.

In conclusion, the Subcommittee on Oversight and Investigations hearing shed light on the prevalent problem of improper payments within Medicaid and Medicare. By confronting this issue head-on and implementing meaningful reforms, policymakers can help safeguard the fiscal integrity of these vital healthcare programs and ensure that program dollars are appropriately used to fulfill the mission of providing healthcare to the nation's most vulnerable populations.

Learn more here. 

MARCH MEDICAID NEWS

Syrtis Solutions issues a monthly Medicaid news roundup to help you stay up-to-date. The monthly recap focuses on developments, research, and legislation that pertains 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 important Medicaid news.

Learn more here. 

MEDICAID IMPROPER PAYMENTS TOTALED $50.3 BILLION IN 2023

 

A new audit by the GAO reveals that the government suffered a significant loss of $236 billion in 2023 because of improper payments. Medicaid and Medicare alone made up 43% of these payments, with Medicaid's improper payments totaling $50.3 billion. These findings underscore the urgent need to address improper payments, which often come from eligibility errors and out-of-date data systems, not widespread fraud and abuse.

By law, Medicaid functions as the payer of last resort, meaning it covers healthcare expenses only after other third-party payers satisfy their obligations. However, discovering these third-party payers has become increasingly difficult as the program expands because of insufficient access to usable eligibility data. The lack of accurate eligibility data has resulted in billions in improper payments for Medicaid plans.

When Medicaid plans discover improperly paid payments, they utilize a "pay and chase" process to recover funds. This approach has built a multibillion-dollar post-payment recovery industry, but unfortunately, for payers of last resort, only 20 cents on the dollar is recouped.

The challenge to identify liable third-party payers has persisted for years, exacerbated by the absence of tech capable of correctly pinpointing active and accurate "other health insurance". Despite legislative efforts and federal initiatives to curb improper payments, the problem has continued, resulting in Medicaid's inclusion on the Government Accountability Office's high-risk list for twenty consecutive years.

How can payers of last resort minimize improper payments?

To mitigate the need for post-payment recovery, Medicaid payers must gain access to timely and accurate eligibility data. Leveraging ePrescribing infrastructures presents a promising solution, as they house some of the most complete and current data on patients' health insurance coverage.

Recognizing this potential, Syrtis Solutions has created ProTPL, a technology-based solution that utilizes ePrescribing eligibility data to help Medicaid plans proactively identify primary payers. ProTPL makes it possible for Medicaid plans to avoid erroneous claims costs upfront by using proprietary logic and advanced matching algorithms, improving the claims process for all stakeholders involved.

Syrtis Solutions' ProTPL addresses the root cause of improper payments by using better data and applying it to avoid erroneous claims payments. ProTPL ultimately decreases costs and improves efficiency in Medicaid claims management.

Click here and learn more. 

FEBRUARY MEDICAID NEWS ROUNDUP

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

Click this link to open the news from February.

MEDICAID ENROLLMENT FORECASTED TO RETURN TO 71 MILLION

Medicaid enrollment is being significantly affected because of the expiration of the continuous enrollment condition authorized by the FFCRA. Since April, millions of people have been disenrolled from the program. Simultaneously, millions of others have either re-enrolled or enrolled in the program for the very first time. 

State data shows that roughly 9.5 million people have been removed from Medicaid since enrollment peaked last April. This trend suggests that Medicaid should go back to its pre-pandemic program size of 71 million members after the unwinding.

Churn in enrollment has long been characteristic of Medicaid. Before the pandemic, an estimated 1 million to 1.5 million people dropped off Medicaid rolls each month.

Many individuals are being disenrolled within a condensed timeframe during the unwinding process. In some states, the situation has proven to be more severe than expected.

The Biden administration at first projected that approximately 15 million individuals would lose coverage during the unwinding phase. However, their estimate was conservative compared to the present data. According to KFF, disenrollments are expected to surpass 17 million, with procedural issues accounting for 70 percent of these instances.

However, roughly two-thirds of the 48 million Medicaid beneficiaries who have undergone eligibility reviews thus far have successfully had their coverage renewed, while about one-third have lost it.

There are, however, significant variations in how enrollment is being affected among states. For instance, Oregon only disenrolled 12 percent of its beneficiaries. KFF reports that 75 percent were successfully renewed, while the remaining cases are still pending. Oklahoma disenrolled 43 percent of its program recipients during the unwinding phase, renewing coverage for only 34 percent. About 24 percent of cases are still pending.

States have varied eligibility requirements, with some implementing policies that make it much easier for members to remain enrolled. For instance, in Oregon, children can remain on Medicaid until the age of 6 without needing to reapply, while all other individuals receive up to two years of coverage regardless of income fluctuations.

Industry experts have expressed ongoing concern about the sharper decrease in Medicaid enrollment among children contrasted to usual trends. This is especially troubling since children usually qualify for Medicaid at higher household income limits than their parents or other adults. According to the latest data from Georgetown University, over 3.9 million children have experienced a loss of Medicaid coverage during the unwinding. 

Utah is the only state to survey those who were disenrolled and found that somewhere around 30 percent were uninsured. Many others obtained employer health coverage or enrolled in subsidized plans through the ACA.

The termination of the continuous enrollment requirement has caused a tremendous impact on Medicaid enrollment. It marks the most significant health coverage transition event since the first open enrollment period of the ACA. Because of varying eligibility requirements across the country, some states are being affected more than others. As they navigate the second half of the unwinding phase, states must make every effort possible to relay enrollment status changes to their program recipients and ensure that their vulnerable populations do not lose coverage. 

Read more here.