COST AVOIDANCE IN MEDICAID WITH E-PRESCRIBING

Medicaid payers face the challenging task of recovering claims payments made in error when program beneficiaries fail to report primary coverage information at the time services are rendered. Plan beneficiaries do not share other coverage information for a number of reasons, but usually, they are not aware that other coverage exists. Without technology at the point of sale to prospectively discover other health insurance (OHI) coverage, payers of last resort cannot help but make claims payments incorrectly. Once it is identified that a claim was the responsibility of another third party payer, Medicaid plans try to recover those payments with a process called pay-and-chase. Unfortunately for payers trying to recover improper claims payments, the actual monies recovered remain around twenty cents on the dollar. Within this post, we will examine a new approach to Medicaid third-party liability cost avoidance. We will explain how e-prescribing functions and how its OHI databases can be used by Medicaid to cost avoid millions of dollars in payments made in error.

What Is E-Prescribing?

An e-prescribing infrastructure provides a safe and secure means to electronically connect patients, healthcare providers, pharmacies, and pharmacy benefits managers (PBMs). It outlines the ability to send error-free, accurate, and understandable prescriptions electronically from the provider to the pharmacist. For an e-prescribing system to function, there must be a master database that keeps consistent, accurate, and current demographic and necessary medical data on the patients seen and managed within its different departments. The need for prompt and accurate OHI data requires the cooperation of health plans and PBMs to provide ongoing active eligibility data to the database.

The Transaction Hub is the common link between the prescriber, pharmacy, and PBMs. The hub directs inquiries to PBMs and prescriptions to pharmacies. For this complex process to operate, the eligibility and demographic data that passes through must be consistent, accurate, and current. This is accomplished through a Master Patient Index.

A master patient index (MPI) is a database used across e-prescribing platforms to maintain consistent, accurate, and current demographic information and essential medical data on the patients seen and managed within its different departments. MPIs are intended to solve the common problem where multiple systems throughout the organization progressively become inconsistent with respect to the patient's most current data; for example, when the patient's information changes and only one system is updated, the changes are not propagated to the others.

When the Transaction Hub receives patient demographics and medication from a healthcare provider, it will verify the patient with the MPI, sending an electronic message to the PBM. In response, the PBM will send information on the patient eligibility, formulary, and medication history back to the Transaction Hub. The Transaction Hub then sends this information back to the healthcare provider, who can make a decision about the prescription based on this information.

Leveraging an E-Prescribing MPI for Medicaid TPL Efforts

As previously stated, the key to an effective e-prescribing system is its MPI, which is continuously being updated by its partners. The eligibility and demographic data that passes through must be consistent, accurate, and current for the system to operate. While an e-prescribing MPI is built specifically for electronically writing prescriptions, we have found another significant use for it in Medicaid TPL cost avoidance.

Anyone involved with Medicaid TPL recognizes that the market needs a technology-based solution to improve recovery efforts. In 2010, Syrtis Solutions began the process of experimenting with the Surescripts MPI to see if we could deliver high-quality, active Rx coverage and corresponding medical coverage that other processes cannot provide. This lead to the development of ProTPL, a real-time point of sale cost avoidance solution.

Through the active participation of almost every PBM and payer in the commercial healthcare marketplace, the Surescripts MPI of more than 280 million covered lives is the largest in the nation. Connectivity to the Surescripts MPI allows for superior OHI discovery.

ProTPL Case Study

In a year-long case study with one of our Medicaid Managed Care customers, for which nearly 3 million transactions were processed, 38,754 utilizing members were found to have OHI. These discoveries resulted in the cost avoidance of $14.6 million in unnecessary claims payments.

The first step to gaining insight into how this solution will benefit your organization is for Syrtis Solutions to perform a no-cost quantitative claims analysis. By checking your claims against the Surescripts MPI, we can, in empirical terms, show you exactly how much your Medicaid plan can save.

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MAY MEDICAID ROUNDUP

 

Syrtis Solutions publishes a monthly Medicaid news recap to help you stay up-to-date. The monthly roundup focuses on developments, research, and legislation that pertains 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 significant Medicaid news.

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MEDICAID'S BILLION-DOLLAR PROBLEM

Improper payments cost Medicaid $86.49 billion in 2020 alone. A frequent misconception is that improper payments stem from fraud and abuse when in fact the majority come from prosaic, mundane problems like eligibility errors and antiquated data systems. Fraud in Medicaid may well still be a significant problem, but when improper payments are the outcome of eligibility errors rather than fraud, the true scope of the challenge can better be addressed.

By law, Medicaid plans are payers of last resort. This means if a beneficiary 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. As the program expands, determining liable third party payers for claims has become increasingly difficult. Plans simply do not have access to the quality eligibility data required to identify third party liability (TPL) before claims are paid. Much of the data traditionally used to prevent improper payments has not been current, available, complete, or accurate. As a result, Medicaid plans continue to make claims' payments in error.

Once new eligibility information is made available and plans discover overpayments, they then try to recoup the funds with a process referred to as "pay and chase." This process has resulted in the development of a multibillion-dollar post-payment recovery industry. Unfortunately, for payers trying to recoup improper claims payments, the actual funds recovered are around 20 cents on the dollar.

Medicaid programs have struggled to effectively identify TPL for decades. One reason is that for the last 40 years, the technology needed to correctly identify TPL has not existed. Over time, improper payments continued to increase, even landing Medicaid on the Government Accountability Office's high-risk list in 2003. Since then, a number of federal efforts have taken place to rein in costs. Legislators have passed new laws, formulated regulations, and held hearings over the issues, and government oversight offices (GAO and OIG) have presented written reports to Congress. Despite legislation and existing TPL processes, the improper payment rate has only increased. While all the initiatives have helped to uncover the scope of the problem, at present, they do nothing to curb improper payments.

If Medicaid payers can detect whether a member has primary coverage before claims are paid, the need for post-payment recovery is mitigated. Additionally, the subset of Medicaid beneficiaries who have unreported primary commercial coverage creates a tremendous opportunity for payers of last resort to get in front of the problem.

How can payers of last resort get access to timely, accurate eligibility data?

Currently, some of the best, most accurate, and current data on patients' health insurance coverage resides in ePrescribing infrastructures. Making use of this resource enables more timely identification of TPL by capturing the needed information on primary coverage that Medicaid members may have. EPrescribing, as a platform, electronically connects patients, providers, pharmacies, and pharmacy benefits managers, and ensures patient eligibility data are accurate and up to date.

Syrtis Solutions realized the potential of ePrescribing data to help Medicaid plans identify primary payers. The solution, ProTPL, uses ePrescribing eligibility data to provide Medicaid plans with a technology-based solution to prospectively avoid pharmacy and medical claims that are the liability of commercial payers. ProTPL is the only service in the marketplace that utilizes proprietary logic required to decipher the complex coding of pharmacy transactions and translate it into actionable eligibility data. Furthermore, Syrtis uses its superior matching algorithm to find primary coverage on members that no other vendor in the marketplace can find.

Syrtis deals with the problem of improper payments on the front end, gathering better data and applying it to avoid claims costs and the expenses associated with recovery efforts. ProTPL has the added benefit of making the claims process better for all involved, including providers. Those involved in the process of Medicaid claims payments have been working with the best available tools. Now, they have new and better tools with Syrtis Solutions.

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APRIL MEDICAID NEWS

 

Syrtis Solutions sends out 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 program 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.

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MARCH MEDICAID NEWS

Syrtis Solutions sends out a monthly Medicaid news summary to help you stay up-to-date. The monthly recap 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. Here is a summary of last month's significant Medicaid news.

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FEBRUARY MEDICAID NEWS RECAP

 

Syrtis Solutions delivers a monthly Medicaid news summary to help you stay informed. The monthly roundup concentrates on developments, analysis, and legislation that pertains to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of February's Medicaid news.

See the news here. 

JANUARY'S MEDICAID NEWS

 

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

Open the news here.