MEDICAID COST AVOIDANCE: UNLOCKING SAVINGS THROUGH BETTER COVERAGE IDENTIFICATION

Cost avoidance is receiving greater attention as Medicaid health plans search for ways to reduce unnecessary spending and make limited healthcare dollars go further. With budgets under pressure and federal oversight evolving, plans need savings strategies that improve financial performance without reducing benefits or creating additional barriers to care.

Some of those savings may already exist within an established Medicaid responsibility: making sure another insurer pays when it is responsible for a member's healthcare costs.

This issue has become increasingly relevant as federal policymakers examine how Medicare and Medicaid address improper spending. A September 2026 majority staff report from the House Committee on Energy and Commerce called attention to the shortcomings of relying heavily on "pay and chase" practices. The report also discussed greater use of data, analytics, and technology to identify potential payment issues earlier.

Although the congressional review is primarily focused on fraud and program integrity, its emphasis on using better information to protect healthcare dollars has clear relevance to coordination of benefits (COB) and third-party liability (TPL).

An Existing Responsibility With Greater Financial Potential

Medicaid is generally the payer of last resort. When other insurance is responsible for a member's healthcare expenses, identifying that coverage helps ensure the claim is directed to the appropriate payer.

The difficulty is that insurance coverage does not remain static.

Members regularly gain, lose, or change commercial coverage. Employment changes, dependent coverage, marriage, and transitions between insurers can all affect payer responsibility. Health plans may not receive information about those changes immediately, leaving active coverage missing from the data used to coordinate benefits.

That delay has a direct financial consequence.

If another insurer is identified only after Medicaid has paid the claim, the plan may need to recover the money retrospectively. When that coverage is identified sooner, the plan has an opportunity to avoid an expense that should have been another payer's responsibility.

For plans under pressure to find savings, improving that timing can make an existing COB/TPL function more financially valuable.

Turning Coverage Intelligence Into Savings

Retrospective recovery will continue to be necessary. Not every coverage change can be known immediately, and some third-party liability will inevitably be identified after claims have been paid.

The opportunity is to reduce the number of cases that reach that point.

A health plan's existing eligibility and coverage information may not capture every active commercial policy. Supplementing those sources with automated insurance discovery can provide a broader view of a member's coverage and identify additional opportunities to coordinate benefits correctly.

The financial impact can extend beyond recovered dollars.

Consider two claims involving members with other commercial insurance. In the first, Medicaid pays and later recovers the expenditure after discovering the other payer. In the second, the commercial coverage is identified in time for the appropriate insurer to assume responsibility.

Both represent successful COB/TPL outcomes. Only one produces a recovery.

The other produces savings by eliminating an unnecessary Medicaid expenditure.

That difference is increasingly important when plans evaluate the effectiveness of their payment-integrity programs. A September 2026 KFF analysis makes a related point in the broader program-integrity context: recovery totals do not fully account for the financial value of prevention and payments that never occur.

For Medicaid health plans, measuring avoided expenditures alongside retrospective recoveries can provide a more complete picture of the financial contribution of COB/TPL.

Expanding the Value of COB/TPL

The objective is not to choose between recovery and cost avoidance. Plans need both.

Recovery addresses claims when other insurance becomes known after payment. Cost avoidance captures savings when better coverage information is available soon enough to establish another payer's responsibility.

ProTPL from Syrtis Solutions is designed to strengthen that process. Using automated algorithmic analysis and insurance discovery engines (AAAIDE), Syrtis identifies other active commercial pharmacy and medical coverage that can supplement the information available to existing COB/TPL operations.

For health plans, the opportunity is straightforward: improve visibility into other insurance, identify more instances in which another payer is responsible, and reduce unnecessary Medicaid expenditures.

That is particularly valuable in today's financial environment because it does not depend on cutting services or reducing access. The savings come from improving the accuracy of payer responsibility and directing healthcare costs where they belong.

Cost avoidance can turn better coverage identification into measurable savings for Medicaid health plans while strengthening an obligation they already have as payer of last resort. As plans look for sustainable ways to manage constrained budgets, expanding visibility into other commercial insurance can help COB/TPL deliver greater financial value without compromising member care.

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THIRD-PARTY LIABILITY CHALLENGES IN MEDICAID

 

Third-party liability, also known as TPL, is the legal requirement of third parties to pay part or all of the expenses for medical assistance under a Medicaid state plan. In other words, if a beneficiary has other forms of health insurance, those primary payers are required to pay their legal liability first, and Medicaid covers any remaining liability as the payer of last resort. This policy has been in place since the Employee Retirement Income Security Act changed the Social Security Act in 1974. However, state Medicaid agencies face ongoing difficulties in meeting TPL requirements, and it is costing the program billions of dollars every year.

This October, the OIG released an updated report that highlighted the particular problems states are encountering in meeting third-party liability requirements and in making sure that Medicaid functions as the payer of last resort. The OIG conducted its audit by sending surveys to Medicaid agency officials to determine how each state collects OHI, identifies TPL, processes claims with TPL, and reports TPL cost avoidance and recoveries. While there has been progress, the OIG's auditing initiatives show that billions of dollars are still at risk. Here is a summary of the report's findings and recommendations.

DIFFICULTIES THAT STATES FACE TO MEET TPL REQUIREMENTS

• According to States, the main challenges in their attempts to meet TPL requirements are related to:

• difficulties acquiring complete, accurate, and up-to-date coverage information from Medicaid enrollees and providers;

• difficulties obtaining timely and reliable coverage details from third parties;

• difficulties coordinating TPL with out-of-State third parties;

• technical issues linked to third-party coverage data received and electronic billing of Medicaid claims with third parties;

• a lack of Federal prompt payment requirements and penalties for third parties that do not cooperate with States' attempts to satisfy TPL requirements;

• difficulties with third parties that deny Medicaid claims for procedural reasons;

• difficulties coordinating TPL with TRICARE and;

• difficulties coordinating TPL with Medicare.

RECOMMENDATIONS TO ADDRESS THIRD-PARTY LIABILITY DIFFICULTIES

The OIG made the following recommendations to CMS to address TPL challenges:

• use the information we received from States about the obstacles they are still experiencing and develop an action plan for helping States more easily identify liable third parties and recover Medicaid payments;

• work with States, as appropriate, to encourage better cooperation from third parties that repeatedly resist States' TPL identification and recovery efforts;

• for the four States we identified as not having fully complied with the DRA's TPL provisions: (1) verify whether the States have since come into compliance and (2) pursue corrective actions for States that have not fully complied;

• verify whether Virginia has returned the $1.25 million Federal share of the Medicaid TPL collections underreported during two fiscal quarters and, if not, require Virginia to refund any remaining amount owed;

• provide guidance to States to assist them with developing processes that improve the reporting of Medicaid TPL amounts on the form 64.9 A;

• ensure that States have current instructions on completing the form 64.9 A;

• ensure that States correctly report TPL amounts on the form 64.9 A; and

• remove or disable lines from the form 64.9 A that States are supposed to leave blank.

MEDICAID PAYERS NEED EFFECTIVE TPL DATA SOLUTIONS

States' TPL difficulties emanate primarily from bad-quality data. Medicaid payers are unable to determine primary coverage on pharmacy and medical claims because the majority of data that they have access to is not current, available, complete, or accurate. As a result, Medicaid plans have no choice but to pay claims in error and then chase reimbursement once other primary health insurance coverage is found. To make matters even worse, the actual monies recovered from these improper payments remain around twenty cents on the dollar.

Without good quality data, Medicaid will not be able to overcome its TPL challenges, and the program will continue to lose billions in improper payments. Syrtis Solutions understood this, and in 2010, introduced ProTPL. Their solution was a real-time point-of-sale cost avoidance service for payers of last resort that provides powerful and accurate eligibility data that plans can act on. ProTPL gives payers of last resort the ability to cost avoid pharmacy and medical claims along with the associated costs of recovery. Syrtis Solutions identifies active health coverage that no other vendors can find by checking claims against the nation's largest and most comprehensive active healthcare coverage information database. Customers implementing ProTPL see an average twenty-five percent increase in OHI discovery. With ProTPL, Medicaid plans can save on claims that are the liability of other primary payers and effectively be the payer of last resort.

In July, Medicaid enrollment climbed to 84.5 million people. Due to the size of the program's population, Medicaid plans need to concentrate on innovative ways of identifying third-party liability, improving efficiency, and reducing costs. Presently, one of the best ways for Medicaid payers to do that is to adopt technology solutions like ProTPL, which will allow them to identify active third-party payers and satisfy TPL requirements.

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BAD DATA IS COSTING MEDICAID BILLIONS

Medicaid currently fails at providing a system that efficiently and accurately stores and utilizes member data. As Medicaid is a joint state and federally run program, there are many problems with coordinating data platforms. Different states have their own unique data processing and storing, and while federal Medicaid data can reveal a clearer picture of consistent problems across state lines, lack of communication and data sharing produces significant barriers. While technology has advanced, gaps in existing data or errors in computation have direct consequences to the swift identification of third party liability (TPL), resulting in costly reimbursement strategies for Medicaid. The lack of uniformity in these systems prevents Medicaid from functioning smoothly.

One of the major challenges facing Medicaid is the lack of quality TPL data. In testimony before Congress in 2012, HHS Regional Inspector General Ann Maxwell delivered an alarmingly unfavorable evaluation pertaining to the reliability of data federal and state authorities use to identify overpayments and fraud in the Medicaid program. She stated, "much of the data used to identify improper payments is not current, available, complete, [or] accurate." A decade later, the exact same issues with TPL data that Maxwell outlined in her testimony to congress exist today. Apart from simple mistakes at the point of service with providers, there are fundamental problems in the health care data used by the Medicaid program that result in the loss of literally billions of dollars a year.

STATE DATA ISSUES

Each state Medicaid agency (SMA) is responsible for delegation of funds and detecting TPL through their own data sources. That being said, states have differing policies and benefits for Medicaid enrollees, producing inconsistent results. State policies may have existing gaps in information or may be so complicated that they are virtually impossible to navigate, leading to administration frustration. The Medicaid Management Information System (MMIS) works to centralize information and uses patient identification numbers to help with payment delegation. That being said, because of the large Medicaid population, in addition to continual churn, these datasets can be cumbersome and create missing information that causes difficult identification of TPL. Furthermore, Medicaid information is not communicated across state lines, creating repetitive errors that could be avoided. Health care organizations may share patient data with Medicaid for payment purposes, but the various types of data management could be an issue when trying to translate to Medicaid-specific forms.

FEDERAL DATA ISSUES

While states may send routine reports to federal Medicaid agencies, a working federal database may have a hard time deciphering the varying information from different SMAs. Data can be lost, infrequently collected, or incorrect across state lines. An individual in one state could move to an adjoining state and lose specific Medicaid benefits. Data might only show a small piece of the big picture and can not properly address the nuances of a social program and the problems that persist across states. Federal guidelines may only guide overarching procedures, and not have control over individual states' Medicaid programs and policies. This disjunction of administration proves difficult when trying to accurately find TPL data for not only individuals, but also states and federal overview.

Data sharing is therefore an efficient and effective way to decrease the number of inconsistencies between states and local organizations that require Medicaid payment. Nevertheless, a slew of issues stem from data sharing in totality. Even within states, health care organizations are hesitant to share patient data. Sacred protected health information (PHI) delegates immense responsibility to hospitals, providers, and care coordinators to handle data cautiously. Even if organizations are willing to share patient data, unique technology systems across health care do not always capture the same data or translate it in the same way. SMAs are responsible to intake this information and identify TPL, which increases difficulty when trying to smooth operations. This reluctance to share information translates to state and federal Medicaid agency issues. Sharing large amounts of diverse data has been troublesome and leads to inconsistent data and high costs to the Medicaid program.

For years Medicaid has struggled to effectively store and utilize program beneficiary data due to disparate data platforms and the inability to accurately share Medicaid data between states and the federal government. Moreover, much of the healthcare data that Medicaid plans do have access to is leading to billions of dollars in improper payments each year. Without having reliable, complete, and accurate TPL data, Medicaid plans will continue to make claims payments in error and rely on costly reimbursement strategies. Plan administrators must look to true TPL technology solutions for additional efficiency and cost avoidance opportunities to protect the program's valuable resources and ensure that plan members receive the care they need.

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COST AVOIDANCE MAKES MORE SENSE

 

Medicaid has become an integral safety net program that gives access to health care for millions of Americans. Payment for this health care is either delegated to Medicaid or other third party insurance coverage. In 2012, 7.6 million people on Medicaid had other private health insurance coverage, and 10.6 million had other public coverage. Medicaid is positioned as the "payer of last resort": if the Medicaid beneficiary has supplemental insurance, that third party insurance is liable for primary payment. The additional insurance coverage is commonly referred to as third party liability (TPL) and creates cost savings for Medicaid by rerouting payment to other forms of insurance before Medicaid must pay. Unfortunately, Medicaid is losing billions of dollars a year because plans are unable to identify TPL.

Identifying TPL is a very complex undertaking because of siloed data, antiquated technologies, and network latency. Medicaid plans attempt to ascertain liable third parties by making use of data matching in several health care data sources. However, they are rarely updated and create several barriers. The challenge of finding accurate TPL frustrates those on the frontlines and creates a stressful, time-consuming search that only occasionally generates results. Claims may already be in progress or completed when TPL is identified. In that case, Medicaid scrambles to get reimbursed for the money they paid for the health care provided when it should have been delegated to a third party for payment. This scrambling is called "pay and chase": Medicaid chases the payment from the third party. Once Medicaid plans identify the liable third party payer, they rarely receive a full refund from the amount originally distributed, and it's costing the program billions of dollars in waste. Typically, Medicaid only recovers a mere 17% of funds used for payment through the "pay and chase" method. "Pay and chase" is clearly ineffective and inefficient. Searching for TPL, identifying the correct distributor, and replacing funds all take additional time and increased administrative costs.

The obvious solution for all parties involved is to identify TPL at the start of the coordination of benefits. Providers are paid faster, administrators have ease identifying the accurate payment provider, and Medicaid enrollees have their services covered. Finding solutions for prospective TPL identification should be made a priority, even more so for a program with such a wide scope and reach as Medicaid. Medicaid plans agree that cost avoidance makes more sense, but until now, the ability to execute it effectively has not been widely available.

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

Identifying primary commercial insurance coverage is incredibly difficult for payers of last resort. Due to the complexity of COB, the near-constant change in the Medicaid population, and bad quality eligibility data, health plans depend heavily on retrospective identification and recovery. Unfortunately, this is costing Medicaid billions of dollars in waste. To protect program resources and ensure that vulnerable populations receive the care they need, plan administrators should look to true TPL technology solutions for further efficiency and cost avoidance opportunities.

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OUTDATED SYSTEMS AND LOW-QUALITY DATA ARE COSTING MEDICAID BILLIONS

 

The government doled out nearly $100 billion in "improper" Medicaid payments in 2021-- accounting for about one-fifth of all Medicaid payments, according to estimates.

The figure represents Washington's current accounting of payments that did not meet the numerous requirements for the Medicaid program, which the federal government manages in conjunction with the states and allows millions of low-income people access to healthcare.

The numbers were also high in 2020, with about $86.5 billion in Medicaid payments deemed improper, or just over 21%.

Medicaid provides healthcare coverage to nearly 80 million people, more than 30 million of which are children. The number of adults enrolled in the program has greatly risen recently, partly because of the pandemic, as well as Medicaid expansion under the Affordable Care Act (ACA).

Improper payments are not synonymous with fraud and abuse, according to analysts and the federal agency that oversees Medicaid and generates the data. "Instead, improper payments are payments that did not meet statutory, regulatory, administrative, or other legally applicable requirements and may be overpayments or underpayments," the Centers for Medicare and Medicaid Services (CMS) says. Improper payments also include payments that may have been valid but where there was not enough data on file at the time of the review to verify they were made properly, according to CMS.

The stunning stats are evidence of a swelling Medicaid regime with obsolete and largely varied state systems for tracking data. Furthermore, federal officials have been using updated criteria to review Medicaid eligibility over the last few years, making it challenging to compare current rates with those of years past.

The figures have nevertheless attracted scrutiny from government watchdogs looking to ensure that billions in tax dollars are being paid and tracked correctly. In February, the inspector general for the U.S. Department of Health and Human Services published a report outlining its past audits to help CMS "in achieving greater efficiencies in its operation of the Medicaid program."

The inspector general's review sampled four states (New York, California, Colorado, and Kentucky) and "found that these States did not always determine Medicaid eligibility" for both newly eligible individuals and those who qualify under old rules "in accordance with Federal and State requirements."

CMS reported actual monetary losses-- cases where officials identified a payment was, actually, erroneously made, were about $11 billion last year. Though it represents a small fraction of total Medicaid spending, it remains a cause for concern, experts say.

"Instead of twisting the [audit] results to fit an erroneous narrative of rampant beneficiary fraud, we should acknowledge that mistakes will be made and act to reduce identified errors collaboratively," Kelly Whitener, a professor at Georgetown University, wrote in 2019.

Missing documentation is another primary factor driving up improper payment rates, according to CMS's data. In 2021, 89% of improper payments were caused by insufficient documentation, representing more than $87 billion in payments. Of those, over half were linked to eligibility determination.

According to CMS reports, the Medicaid overpayment rate swelled from 9% in 2018 to 21% in 2020. In the 2020 report, CMS said that year's figures couldn't be compared to those before 2019, though, because that's when it implemented a key change in the eligibility rules it uses to audit payments.

The Payment Error Rate Measurement audit program (PERM) is what produces improper payment rates each year and operates on a three-year cycle. "CMS paused PERM eligibility reviews from 2015 to 2018, as states were implementing new rules under the Affordable Care Act for determining eligibility for many beneficiaries," the agency said.

Jessica Schubel, a senior policy analyst at the Center on Budget and Policy Priorities, said "most eligibility errors reflect paperwork problems or other procedural mistakes that can easily occur when eligible people enroll." For example, an incorrect code (where a state inadvertently assigns the parent eligibility code to an eligible child) is considered an improper payment. In another example, a caseworker could fail to determine if the enrollee has primary commercial coverage.

In general, the data and documentation problems within the Medicaid system mean that determining the actual fraud rate is challenging. "I don't know anyone who knows the answer. I certainly don't," Andy Schneider, a professor at Georgetown University said when asked what he believed the actual fraud levels were. All he knows, he said, is that "the rate of fraud varies from state to state" and "most of the state and federal government's losses from Medicaid fraud are attributable to providers or managed care plans, who receive Medicaid payments, and not to applicants or beneficiaries, who don't." "Of the 77 million Medicaid beneficiaries as of November 2021, 33 million, or over 40%, were children," he said. "Few of whom would even know what fraud was, much less commit it."

Medicaid improper payments have risen throughout the years and while PERM brings the problem into scope, it does nothing to reduce them. These payments often stem from fraud and abuse but the vast majority are actually a result of eligibility errors from antiquated systems and low-quality data. To reduce improper payments states and Medicaid plans must turn to data solutions to improve the coordination of benefits and identification of third party liability.

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THIRD PARTY LIABILITY REQUIREMENTS IN THE MEDICAID PROGRAM

The Social Security Act, signed into law by President Franklin Roosevelt in 1934, stipulates in the statute § 1902( a)( 25) of the law "... that the State or local agency administering such plan will take all reasonable measures to ascertain the legal liability of third parties ... to pay for care and services" delivered to Medicaid recipients. Essentially, it means that Medicaid becomes the payer of last resort, a term also known as third party liability, or the coordination of benefits. In other words, Medicaid pays last, and if a Medicaid member holds other coverage, such as insurance from an employer, that insurer pays first, and then Medicaid pays any remaining costs.

As much as 10 percent of the Medicaid members across the nation hold additional insurance besides Medicaid, which is considered TPL. Types of TPL include employee insurance, Workers' Compensation, Medicare, COBRA insurance from past employment, casualty insurance, dental insurance, eye insurance, and insurance to cover pharmaceutical costs.

The Deficit Reduction Act passed by Congress in 2005 stipulates in Section 6035 that states are directed to pass laws that force health insurance companies to give the state health insurance premium data involving people who are eligible for Medicaid assistance. Specifics of the DRA include:

• Health insurance companies must hand enrollment information over to Medicaid, or its agent, so member benefits can be coordinated.
• This information is to be used to identify supplementary health insurance coverage so that improper payments are not made and payments made in error are recovered.
• Payments are required to be made as long as the claim is submitted within three years after the medical service was provided.
• Claims cannot be denied as long as the state started action on the claim within six years after the state submitted the claim.

Specifications must be made that health insurance consists of other entities that are by statute, agreement, or contract, legally responsible for paying a claim of a healthcare service; pharmacy benefit managers; managed care organizations; group health plans; and self-insured plans.

IDENTIFYING THIRD PARTY LIABILITY IN MEDICAID

Determining primary health insurance coverage of Medicaid beneficiaries can be achieved by a state through one of three different approaches and still allow the state to comply with TPL criteria, under federal law. The problem is that if only one approach is implemented by the state, savings and recovery are not at their greatest possible amount. The highest level of savings consists of processing at all three of the following points in the process by the state. Here are those processes:

Applicants enrolling in the program are asked about other insurance coverage.

The issue is that some enrollees assume they will be disqualified from Medicaid, so this information is withheld. And, since adding Medicaid coverage might also imply an employment change in which employer insurance coverage is lost, this disclosure might be immaterial soon after the applicant's enrollment.

The state looks for TPL coverage in order to avoid extra cost.

Medicaid eligibility names are cross-referenced with names enrolled in state and national health insurance companies in order to detect primary insurers before the submission of Medicaid claims. But, this practice becomes impossible unless state rules require the timely delivery of insurance data when a state also requires the prompt payment of insurance claims. Additionally, a number of medical services, like those dealing with a pregnancy, must be paid at the time that they are claimed, according to federal law. That means that pregnancy claims have to be paid immediately before recovery can be made from responsible insurers.

Improper payments are recovered.

The third part of a comprehensive TPL plan involves Medicaid's payment, which occurs one of two ways. Medicaid can offset the service provider during the next payment issued for the amount that was overpaid. This is called "provider disallowances." Or, Medicaid receives the overpayment from the correct insurance carrier. This is called commercial insurance direct billings. Strong state policies are required for this third step in a TPL plan to function, since without it, the state can receive denials from insurance companies. The bottom line is that when payment errors are cost avoided, time is not wasted in pay and chase activities.

WHAT AN EFFECTIVE TPL PLAN NEEDS TO INCLUDE

So, in order to gain an efficient TPL plan, immediate and effective discovery of additional coverage is needed at Medicaid enrollment. Also, cost avoidance discovery must take on immediacy when claims are made and past errors need to be resolved quickly. What works best is when the federal directives and state laws mesh to form a truly thorough DRA policy that realizes other health insurance coverage with quick recovery of each claim.

ProTPL offers a solution that provides this critical information in real-time, at the point of sale.

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ASCERTAINING MEDICAID TPL

The majority of Medicaid improper payments occur as a result of antiquated data systems that lead to eligibility errors. As the Medicaid program has expanded, finding primary commercial coverage, also referred to as Third Party Liability (TPL), has become significantly more complicated and challenging. By law, Medicaid plans are payers of last resort. This means if a plan member has health care coverage through any other third party, that third party must pay its legal liability first. If any liability remains, Medicaid plans will then pay. According to the Centers for Medicare and Medicaid Services (CMS), "States are required to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services that are available under the plan."

This rule has been in place since the Employee Retirement Income Security Act (ERISA) modified the Social Security Act in 1974. To this day, ascertaining TPL remains a difficult challenge. Coordination of benefits (COB) is no easy task. CMS explains that COB is achieved by, "determining Medicaid benefits when an enrollee has coverage through an individual, entity, insurance, or program that is liable to pay for health care services."

WHERE TPL IS IDENTIFIED

The discovery of liable third parties happens at three points in the lifecycle of a Medicaid beneficiary. This identification of unknown primary insurance coverage may occur in the course of the enrollment process, prospectively before claims are paid, and retrospectively after an improper claims payment has been made.

In the enrollment phase, Medicaid applicants are approved and their self-reported TPL is validated and reported to the state. The main challenge is that over 13% of the Medicaid population has unreported TPL. Applicants are often not aware of other health insurance or fail to disclose it at the time of enrollment. At the point of service-- when recipients are presenting insurance information to care providers-- they might not furnish proof of primary coverage. The system is undoubtedly complex, and members may not realize that they have valid primary coverage, and even if they do, it is unlikely that they are familiar with the concept of payers of last resort. Compounding the confusion, the Medicaid population is in near-constant flux, with individuals becoming eligible and ineligible for services depending on a number of factors such as income and disability status.

Once an applicant is enrolled, plans undertake ongoing prospective identification of other insurance coverage. The difficulties here are the same issues that are responsible for the high amount of improper payments in the Medicaid program. That is, existing data mining and matching models are antiquated and need constant verification. Sometimes, a Medicaid plan uses an outside vendor to conduct monthly eligibility checks in an attempt to discover a Medicaid member's TPL. However, the data available to these vendors suffer the same antiquation and inaccuracy problems. Though health plans make an effort to discover TPL in as timely a manner as possible, there are many obstacles.

The final point at which health plans can discover TPL is retrospectively after claims are paid in error. At present, pharmacy and medical claims reviews are profoundly retrospective, which creates a multitude of problems for improper payments. Consequently, a post-payment recovery process, known as 'pay and chase,' is needed to recoup the claims payments that were made in error.

Beyond simple mistakes at the point of service with providers, there are fundamental problems in the health care data used by the federal government that lead to the loss of literally billions of dollars a year.

One of the major challenges facing Medicaid is the lack of high-quality eligibility data. In testimony before Congress in 2012, HHS Regional Inspector General Ann Maxwell gave an alarmingly unfavorable assessment relating to the reliability of data the federal government uses to detect overpayments and fraud in the Medicaid program. She explained, "much of the data used to identify improper payments and fraud is not current, available, complete, [or] accurate."

Identifying primary commercial coverage is extremely difficult for payers of last resort. Due to the complexity of COB, the near-constant flux in the program's population, and bad quality eligibility data health plans rely greatly on retrospective identification and recovery. Unfortunately, this is costing Medicaid billions in waste. To coordinate claims effectively, payers of last resort must look to new data solutions that determine TPL before claims are paid in error.

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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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MEDICAID TPL AND IMPROPER PAYMENTS LEGISLATION

Throughout the last fifty years, Medicaid has helped provide health services to the most vulnerable populations in the United States. As member enrollment rises, Medicaid TPL and fiscal responsibility have been problematic. To address these challenges, numerous legislative efforts have occurred to curb fraud, waste, and abuse. Unfortunately, these measures have done very little to protect program integrity and Medicaid's improper payment rate continues to climb.

Improper Payments and Medicaid TPL Legislation

The federal government's efforts to combat improper claims payments and improve TPL processes fall into four categories:

• Assessing the risk of fraud
• Estimating the impact of TPL
• Requiring more reporting
• Increased data sharing

Here is an overview of the legislation aimed towards improving Medicaid TPL and reducing improper payments.

1974 - ERISA

Congress passed the Employee Retirement Income Security Act (ERISA) in 1974. This law was aimed at self-insured companies to ensure that they abided by the same health insurance criteria as other large group plans. Additionally, it placed them under Medicaid TPL requirements.

2002 - IPIA

The Improper Payments Information Act (IPIA), passed in 2002, required agencies to actively identify programs or activities subject to high levels of improper payments. Agencies were now directed to make an annual report to Congress pertaining to overpayments or underpayments and measures taken to address such issues. In compliance with the IPIA, the Payment Error Rate Measurement (PERM) was created. PERM reviews Medicaid and CHIP data to measure improper payments and determine program-level error rates.

2005 - The Deficit Reduction Act

The Deficit Reduction Act (DRA) added additional entities to the list of those considered third parties. By law, all entities identified as third parties are mandated to observe Medicaid TPL processes, which includes supplying beneficiary eligibility data to states (much like ERISA dictates for self-insured plans).

2006 - Medicaid Integrity Program

The DRA also introduced the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act. The MIP was the first extensive federal initiative to combat fraud, waste, and abuse. It allowed contractors to review provider activities, audit claims, identify improper payments, and educate providers on integrity issues. It also provided support to states to address fraud and abuse.

2008 - Qualifying Individual Program Supplemental Funding Act

The Qualifying Individual (QI) Program Supplemental Funding Act of 2008 modified state participation criteria of the Public Assistance Reporting Information System (PARIS). It called for states to link their eligibility systems through PARIS, providing data for matching purposes across participating entities. CMS discovered that beneficiaries crossing state lines were one source of improper payments since a mechanism did not exist for states to share data and "match" beneficiary information.

2009 - Executive Order 13520

Executive Order 13520 was an effort to lower Medicaid improper payments. It looked to intensify efforts to eliminate payment errors, waste, fraud, and abuse while at the same time ensuring that Medicaid and other federal programs would continue to serve their beneficiaries. EO 13520 tracked federal programs with the highest dollar amount of improper payments and established reduction and recovery target rates.

2010 - Improper Payments Elimination and Recovery Act

Congress passed the Improper Payments Elimination and Recovery Act of 2010 to improve data sharing, coordination between state agencies and third parties, and increase reporting requirements. Some of the measures taken include:

• Amendment of the IPIA to require the leader of each federal agency to review and determine vulnerabilities in their programs that could lead to improper payments

• Modifications of the criteria related to improper payment estimations

• Requirement of a report from agencies as to whether it has "sufficient resources with respect to internal controls, human capital, and information systems and other infrastructure to prevent improper payments"

2015 - Fraud Reduction and Data Analytics Act

The Fraud Reduction and Data Analytics Act called for the Office of Management and Budget to establish new guidelines for federal agencies to improve TPL management. Under the act, agencies needed to "establish financial and administrative controls to identify and assess fraud risks." Furthermore, agencies were expected to submit annual reports to Congress regarding their progression on these efforts.

2015 - Federal Improper Payments Coordination Act

Congress also passed the Federal Improper Payments Coordination Act in 2015. It addressed administrative operations, reporting guidelines, and data-sharing to improve TPL and cost avoidance. Under the act, the judicial branch, legislative branch, and state government agencies managing federal programs were authorized to use the U.S. Treasury Department's Do Not Pay Program.

2015 - Medicare Access and CHIP Reauthorization Act

The Medicare Access and CHIP Reauthorization Act of 2015 consisted of several sections relevant to Medicaid programs, including a section impacting TPL data sharing. It instructed the Secretary of HHS to look at "incentives for states to work with the Secretary under the Medicare-Medicaid Data Match Program."

ProTPL Saves Medicaid TPL Millions

Discovering Medicaid TPL is very difficult for program administrators as they deal with bad quality data that is not up to date, usable, or correct. Since they are not able to effectively determine TPL before claims are paid, improper payments are costing Medicaid billions of dollars. Medicaid plans agree that cost avoidance makes more sense than pay and chase, but the ability to execute it effectively has not been widely available. Now, through Syrtis Solutions' ProTPL, payers of last resort are able to cost avoid pharmacy and medical claims on the front end. Their solution minimizes the need for recovery and the associated expenses while cost avoiding payments. Those involved in the process of Medicaid claims adjudication have been working with the best tools they had available. Now, they have new and better tools through Syrtis.

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A TIMELINE OF LEGISLATIVE INITIATIVES TO ADDRESS MEDICAID THIRD PARTY LIABILITY

Since Medicaid's inception in 1965, the program has expanded to become the largest provider of healthcare coverage in the country. As the size of the member population has increased, Medicaid third party liability (TPL) efforts and fiscal responsibility have been persisting concerns. To protect Medicaid's solvency, there have been several legislative efforts focused on curbing fraud, waste, and abuse. Unfortunately, these actions have done very little to preserve the program's integrity and Medicaid's improper payment rate has hovered around 10% for the last ten years.

Federal initiatives to fight improper payments fall under the following categories: assessing the risk of fraud; estimating the impact of TPL; requiring more reporting, which in turn creates administrative burden; and efforts to increase data-sharing. Here is a review of legislation aimed at strengthening TPL and decreasing improper payments.

EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA)

ERISA was directed towards self-insured companies and mandated that they abided by the same health insurance criteria as other large group plans. This was important because self-insured plans were now subjected to Medicaid TPL stipulations.

IMPROPER PAYMENTS INFORMATION ACT OF 2002 (IPIA)

The IPIA concentrated on evaluating and reporting improper payments. It required that agencies, on an annual basis, identify programs and activities susceptible to substantial improper payments. In addition, agencies needed to estimate the amount of overpayments or underpayments and then report on steps being taken to decrease the payments.

DEFICIT REDUCTION ACT OF 2005 (DRA)

In an effort to rein in costs, Congress signed the DRA into law in 2006. It included key Medicaid provisions and broadened the list of entities regarded as third parties. In a similar way to ERISA, the DRA required all third parties to abide by Medicaid TPL processes and to supply beneficiary information to states so as to improve cooperation in data sharing.

The DRA also launched the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act. The MIP was the first comprehensive Federal effort to deal with fraud, waste, and abuse. It allowed contractors to review provider activities, audit claims, identify improper payments, and educate providers on integrity issues. It also provided assistance to states to address fraud and abuse.

QUALIFYING INDIVIDUAL (QI) PROGRAM SUPPLEMENTAL FUNDING ACT OF 2008

The QI changed state participation requirements for the Public Assistance Reporting Information System (PARIS). Under the legislation, states were required to have in operation a Medicaid eligibility determination system for data matching through PARIS and medical assistance programs operated by other states.

EXECUTIVE ORDER 13520

In 2009, President Barack Obama authorized Executive Order 13520 "to reduce improper payments by intensifying efforts to eliminate payment error, waste, fraud, and abuse in the major programs administered by the Federal Government, while continuing to ensure that Federal programs serve and provide access to their intended beneficiaries." A few of the order's notable plans involved identifying Federal programs with the highest dollar value of improper payments, developing reduction and recovery target rates for these programs, guidance for implementation of the order, and reporting on how agencies planned to meet the targeted rates.

IMPROPER PAYMENTS ELIMINATION AND RECOVERY ACT OF 2010

The Improper Payments Elimination and Recovery Act took several steps to further enhance data sharing, coordination between state agencies and third parties, and increase reporting requirements. These included:

• Amendment of the IPIA to require the agency leaders, such as the Secretary of HHS, to review and identify vulnerabilities in their programs that could lead to improper payments.
• Modifications of the criteria for improper payment estimations.
• Requirement of a statement from agencies as to whether it has "sufficient resources with respect to internal controls, human capital, and information systems and other infrastructure to prevent improper payments."

FRAUD REDUCTION AND DATA ANALYTICS ACT OF 2015

The Fraud Reduction and Data Analytics Act required the Office of Management and Budget to develop new guidelines for Federal agencies. Under the act, Federal agencies needed to "establish financial and administrative controls to identify and assess fraud risks," and they were also required to submit annual reports to Congress regarding their progress on these efforts.

FEDERAL IMPROPER PAYMENTS COORDINATION ACT OF 2015

After the Fraud Reduction and Data Act of 2015, Congress successfully passed the Federal Improper Payments Coordination Act. This authorized the judicial branch, legislative branch, and also state government agencies managing Federal programs to utilize the U.S. Treasury Department's Do Not Pay (DNP) Program. The DNP is a "no-cost robust analytics tool which helps Federal agencies detect and prevent improper payments made to vendors, grantees, loan recipients, and beneficiaries." Through the Fraud Reduction and Data Act and The Federal Improper Payments Coordination Act, Congress focused on administrative procedures, reporting requirements, and data-sharing; all of which were devised to improve cost-avoidance and address TPL.

CHIP REAUTHORIZATION ACT OF 2015 (MACRA)

MACRA included a variety of sections relating to Medicaid programs, including a section affecting TPL issues. Sec. 510 "requires the Secretary to study and detail incentives for states to work with the Secretary under the Medicare-Medicaid Data Match Program to coordinate appropriate actions to protect the Federal and state share of expenses under the Medicare and Medicaid programs."

TECH SOLUTIONS FOR MEDICAID THIRD PARTY LIABILITY

The identification of Medicaid third party liability has become difficult for program administrators and is costing plans billions of dollars in improper payments. Medicaid plans agree that cost avoidance makes more sense than pay and chase, but until now the ability to execute it successfully has not been widely available. With the help of Syrtis Solutions and their exclusive ePrescribing data, payers of last resort are now able to cost avoid pharmacy and medical claims on the front end. EPrescribing data surely was not originally intended for these purposes. However, its ability to mitigate the need for recovery and the associated expenses while cost avoiding payments is undeniable. Those involved in the process of Medicaid claims payments have been working with the best tools they had available. Now, they have new and superior tools through Syrtis.

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MEDICAID THIRD PARTY LIABILITY REVIEW FROM THE GAO

Identifying third party liability continues to be a challenge within the coordination of benefits for Medicaid. By law, plans are payers of last resort so whenever beneficiaries have other active coverage (OHI), those third parties should pay first. Presently, plans are required to incorporate new payment procedures to aid in ensuring that they do not pay more than they should. Despite the requirement, CMS is unsure as to whether or not plans have implemented the new procedures and the GAO is advising that the agency determines compliance.

The new payment procedures were enacted as part of The Bipartisan Budget Act of 2018. Before the legislation, Medicaid plans would regularly pay providers for services and then look for reimbursement from any liable third parties. This retrospective approach is known as Pay and Chase. Additionally, the law included a provision for the GAO to evaluate the potential impact of the legislation.

In August, the GAO released their report which included their discoveries and recommendations. They found that nine of the states reviewed are in various stages of implementing the law's third party liability changes. These changes affect whether providers must seek payment from a liable third party before the Medicaid plan pays for services. The new procedures apply to prenatal care services, pediatric preventive services, and services for children subject to child support enforcement. The report went on to point out:

"Officials from four of the nine selected states reported having fully implemented the changes for prenatal care services, which were required to be implemented starting in February 2018. Officials from the remaining five states were discussing the changes internally, researching how to implement the changes in their Medicaid payment systems, or waiting for additional guidance from the Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for overseeing states' Medicaid programs."

"None of the nine states had implemented the changes to pediatric preventive services and services for CSE beneficiaries, which must be implemented starting in October 2019. Officials from six states told GAO that they were in the early stages of exploring how they would make the changes, while the remaining three states had not developed such plans."

The GAO also found issues with the guidance that CMS issued to states for implementation of the third party liability changes. CMS's guidance incorrectly informs plans that providers are not required to seek payments from OHI before plans pay for some prenatal services.

The report also reveals that CMS is not adhering to its oversight responsibilities. It specifies that the agency has not effectively determined whether plans are complying with the updated third party liability requirements. CMS expects plans to comply, yet it does not verify that the changes have been implemented unless informed of non-compliance.

The GAO also discussed the impact of the changes with Medicaid specialists and stakeholders. According to the stakeholders, the new requirements could possibly result in a reduction in beneficiary access to care because providers would be less willing to see Medicaid patients. The two primary reasons are:

1. "The changes may increase administrative requirements for providers by requiring them to identify sources of coverage, obtain insurance information, and submit claims to third-party insurers before submitting them to Medicaid."
2. "The changes may result in providers waiting longer to receive Medicaid payment for certain services to the extent that states require providers to seek third-party payments before paying the providers' claims."

Lastly, the GAO report featured two recommendations to CMS. One of which was to ensure that the agency's guidance on third party liability requirements reflects current law and the other was to figure out the extent to which plans are complying with third party liability requirements.

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