MARCH MEDICAID NEWS

 

Syrtis Solutions publishes a monthly Medicaid news summary to help you stay up-to-date. The monthly roundup concentrates on developments, analysis, 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 important Medicaid news.

Read March's news. 

FEBRUARY MEDICAID RECAP

 

Syrtis Solutions issues a monthly Medicaid news summary to help you stay up-to-date. The monthly summary 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. Below is a list of last month's important Medicaid developments.

See the news. 

MEDICAID IS LOSING BILLIONS FROM ELIGIBILITY ERRORS

Since its passage in 1965, the Medicaid has grown to become the single largest payer for health care in the United States, costing $671.2 billion in 2020. Because of surges in enrollment from the pandemic and the present administration's priorities, spending is only projected to increase. Considering that Medicaid improper payments now make up more than twenty percent of federal Medicaid expenditures, this is a cause for concern. Improper payments are threatening the program's solvency and sustainability.

In FY 2021 alone, Medicaid's estimated improper payments amounted to an enormous $98.72 billion. A typical misunderstanding is that this waste originates from fraud or abuse when in fact, it is overwhelmingly due to eligibility errors. According to the Foundation for Government Accountability (FGA), 80 percent of improper payments stem from individuals receiving benefits who are not eligible for the program. This problem has become such an issue that, "improper payment rates have reached as high as nearly 50 cents for every Medicaid dollar spent in some states."

In a recent interview, Hayden Dublios, Deputy Research Director for the FGA, stated "What's interesting is that most of the improper payment rates are pre-COVID, so we may not know how high the number really is yet."

The FGA's study investigated the improper payment problem by sampling a number of states and compared their improper payment rates with the national average using data from CMS and other sources. What they found was concerning. Ohio's improper payments rate was 44 percent, and 98 percent of those payments were because of eligibility errors. Illinois had an improper payment rate of 37 percent, and ineligible enrollees accounted for 95 percent of it. Kansas had an improper payment rate of 28 percent and 99 percent of its improper payments also stemmed from eligibility errors.

In March of 2020, The Families First Coronavirus Response Act increased Medicaid funding by 6.2 percent to support states during the pandemic. Under H.R. 6201, states were prohibited from altering eligibility, adjusting enrollment processes, or disenrolling members from the program, despite eligibility, until the end of the pandemic. When the FGA reviewed data from 17 states, they identified that about 90 percent of new enrollees from during the pandemic are no longer eligible for Medicaid. In fact, by the end of 2021, 17 million enrollees were ineligible. They advise that states remove ineligible enrollees to lower costs and that states should not fear a clawback due to the guidance published by CMS.

MEDICAID CAN COST AVOID AND SAVE

To decrease eligibility errors and improper payments, States must look to improving program efficiency with cost avoidance opportunities. Ultimately, eligibility errors arise from bad quality data and outdated TPL processes, not intentional fraud and abuse. Payers of last resort struggle to identify primary coverage on pharmacy and medical claims. The majority of the data they have access to is not current, available, complete, or accurate. Because of this, plans have no choice but to pay claims in error and seek reimbursement once other health insurance (OHI) is found. Unfortunately, the actual monies recovered remain around twenty cents on the dollar.

Syrtis Solutions recognized that Medicaid plans needed a way to detect active OHI coverage so that claims could be adjudicated correctly. So, in 2010, they launched ProTPL, a real-time point of sale cost avoidance solution for the payer of last resort market. ProTPL provides powerful and accurate eligibility data that can be acted upon. The solution gives payers of last resort the ability to cost avoid pharmacy and medical claims and the associated costs of recovery. In addition, 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 adopt 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.

Surges in Medicaid enrollment over the past two years have increased the chances for waste in the program. This is a problem because Medicaid is currently losing billions every year in improper payments. Right now, one of the most significant opportunities for reducing costs lies within the coordination of benefits. Plan administrators should look to TPL technology solutions for further efficiency and cost avoidance opportunities.

Read more here. 

JANUARY MEDICAID ROUNDUP

Syrtis Solutions publishes a monthly Medicaid news roundup to help you stay informed. 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. Here is a summary of last month's significant Medicaid news.

Read the news here. 

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.

Read more.

MEDICAID 2021 - A YEAR IN REVIEW

 

Syrtis Solutions distributes a year-end Medicaid review to help you stay informed. The yearly roundup concentrates 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 year's important Medicaid developments.

Read here. 

MEDICAID NEWS IN DECEMBER

Syrtis Solutions publishes a monthly Medicaid news roundup to help you stay up-to-date. The monthly recap 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 important Medicaid news.

Click here to read.