MEDICAID IMPROPER PAYMENTS & UNREPORTED COMMERCIAL COVERAGE: A RAPIDLY ESCALATING BUDGET THREAT

 

Medicaid improper payments have become one of the most serious pressures facing Medicaid programs today. In 2024 alone, these errors totaled $31.1 billion, consuming funds that states cannot afford to lose. A large share of this waste occurs when Medicaid unknowingly pays claims that should have been billed first to a commercial insurer. This problem persists because states lack timely, accurate visibility into whether a beneficiary holds other health insurance.

Nearly 10 percent of Medicaid members currently have commercial coverage that is never identified by traditional processes. States continue to rely on eligibility files that lag behind reality, outdated verification systems, and fragmented coordination of benefits workflows. With these limitations, Medicaid ends up paying incorrectly—and the recovery efforts that follow rarely reclaim more than a fraction of the dollars that should never have gone out in the first place. Every one of these improper payments represents a preventable loss that weakens the program and limits the services it can support.

THE BIG BEAUTIFUL BILL: AN ENVIRONMENT OF TIGHTER CONSTRAINTS

The financial stakes will rise even higher under the Big Beautiful Bill, which imposes new federal constraints on how states can operate and fund their Medicaid programs. The law tightens eligibility rules, reduces flexibility around revenue generation, and places states in the difficult position of having to either increase funding or cut benefits and services.

With less room to maneuver, the need to control unnecessary spending becomes urgent. Preventing improper payments through accurate identification of third-party liability (TPL) is no longer optional—it is essential to protecting Medicaid’s financial foundation.

SYRTIS SOLUTIONS DELIVERS REAL-TIME COST AVOIDANCE

Syrtis Solutions helps Medicaid programs confront this challenge directly by stopping improper payments before they occur. ProTPL, the company’s real-time TPL technology, identifies unknown commercial coverage before Medicaid becomes the payer. Through exclusive access to the country’s largest ePrescribing network, ProTPL provides a level of visibility that traditional vendors cannot match.

Medicaid payers that implement ProTPL routinely discover significantly more commercial coverage—often about 25 percent more than their legacy processes reveal. This leads to immediate reductions in improper payments and dramatically lowers the dependence on slow, resource-heavy pay-and-chase models. Instead of chasing lost dollars, states keep those dollars inside the Medicaid program where they belong.

ProTPL integrates seamlessly with existing systems, requires minimal operational disruption, and fully supports federal TPL compliance requirements. With a transaction-based pricing model and a proven history of success among major health plans, Syrtis Solutions offers a reliable and scalable way to strengthen program integrity, preserve provider relationships, and safeguard strained budgets.

UNCOVER THE SAVINGS YOU’RE MISSING

To help Medicaid payers quantify their exposure, Syrtis offers a free claims analysis that evaluates the plan’s own data. This review identifies gaps in current TPL workflows and highlights avoidable spending that may be slipping through undetected. These insights often reveal savings opportunities that can have an immediate impact on financial performance.

For states facing intensified budget pressure and shrinking flexibility, identifying these opportunities early can support smarter decision-making, stronger oversight, and long-term fiscal stability.

Discover more here.