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 These findings underscore the urgent need to address improper payments, which often come from eligibility errors and out-of-date data systems, not widespread fraud and abuse.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.
