MEDICAID REFORM AND TECHNOLOGIES HELP STATES CUT COSTS

As Medicaid enrollment swells and costs continue to rise, while budget cuts are being considered, state governments are reaching a critical decision point. What was already one of the most expensive state programs has become even more costly, now accounting for close to 33% of many state budgets. Pandemic-era protections and Medicaid expansion policies helped millions gain coverage, but they also exposed systemic inefficiencies that states can no longer afford to overlook.

Now, with post-pandemic budget tightening underway, states are taking a hard look at how to rein in Medicaid spending without compromising access to care.

A DECADE OF BILLIONS LOST TO IMPROPER PAYMENTS

Improper payments remain one of Medicaid’s most persistent and expensive problems. In fiscal year 2023, more than $50 billion in payments were made in error, according to CMS. The primary culprits? Poor documentation and weak eligibility verification.

Improper Medicaid payments have topped half a billion dollars over the last ten years—money that could have been redirected to essential services or stretched existing healthcare budgets further. For states already facing economic headwinds, these avoidable losses are unsustainable.

STATES ENACT REFORMS TO STRENGTHEN PROGRAM OVERSIGHT

In response, many states are advancing legislation and policy changes to bring accountability and accuracy back to Medicaid operations:

• Indiana eliminated self-attestation in favor of regular eligibility checks using government databases and implemented quarterly reporting on fraud prevention efforts.

• Texas has expanded the use of third-party and federal tax data to verify Medicaid eligibility and has invested in modernized systems to increase automation and accuracy.

• Florida and Missouri are doubling down on frequent eligibility redeterminations and greater scrutiny of Managed Care Organizations (MCOs).

• Arkansas and Georgia have rolled out stricter redetermination schedules and automated eligibility verification to reduce enrollment errors.

These actions reflect a coordinated shift toward data-driven oversight and stricter controls to prevent ineligible individuals from remaining on the rolls.

TECHNOLOGY: THE ENABLER OF REAL-TIME INTEGRITY

To make these policies effective and scalable, states are increasingly adopting purpose-built technologies that can automate and enhance the integrity of the Medicaid program. One such solution is ProTPL from Syrtis Solutions—a real-time third-party liability detection platform.

ProTPL helps Medicaid programs meet federal coordination of benefits (COB) requirements and improve cost avoidance by:

• Flagging claims with existing commercial coverage before payment is issued,

• Automating verification tasks that would otherwise require manual follow-up,

• Minimizing administrative overhead while improving audit readiness,

• Ensuring that Medicaid remains the payer of last resort, as intended by law.

By shifting from “pay-and-chase” recovery tactics to preemptive cost avoidance, ProTPL supports faster, cleaner operations while saving states millions.

A MODERN MEDICAID SYSTEM REQUIRES BOTH POLICY AND TECH

For Medicaid to remain sustainable, states need to rethink not just what is being done, but also how it is being done. The best policy in the world can’t succeed if the systems enforcing it are outdated or underpowered. That’s why the combination of reform-driven governance and real-time technology is emerging as the most effective strategy.

States that align legislative reform with innovations like ProTPL will be better equipped to:

• Protect public funds,

• Deliver accurate, timely care,

• And restore confidence in the long-term viability of Medicaid.

This is not just about fixing what’s broken—it’s about building a smarter, stronger Medicaid program that can adapt to modern demands.

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