DO YOU KNOW HOW MUCH IMPROPER CLAIMS PAYMENTS ARE COSTING YOUR SMA OR MCO?

 

Improper claims payments cost Medicaid billions each year. A frequent misconception is that these payments stem from fraud and abuse. In truth, the vast majority stem from issues such as eligibility errors and outdated data systems. Don't miss out on this opportunity to receive a free quantitative claims analysis to see how much your organization can save by reducing improper claims payments.

See how you can save here!

JULY MEDICAID NEWS RECAP

 

Syrtis Solutions delivers a monthly Medicaid news summary to help you stay informed. The monthly summary focuses 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 summary of last month's significant Medicaid news. 

Click here to learn more. 

MEDICAID WORK REQUIREMENTS RETURN

 

In 2018, the Trump Administration and GOP made multiple attempts to reverse the ACA and establish federal spending caps on the Medicaid program to lower costs. These attempts were not successful; nonetheless, a number of states expanded their Medicaid programs and proposed work requirements during this time.

According to KFF, one out of five Americans receive health care through Medicaid. The program has become the country's largest source of health care coverage and accounts for 27% of state expenditures. Due to program expansion and costs, House Republicans renewed their push for work requirements over the spring during debt ceiling negotiations with Democrats. They also suggested expanding the work requirements for individuals receiving food and cash assistance through SNAP and TANF.

The Medicaid work requirement provision did not make it through negotiations; however, President Biden agreed to the expanded work requirements for food and cash support in exchange for a two-year suspension of the debt ceiling. Despite the outcome in Washington, some states are still pursuing work requirements for their Medicaid programs with special waivers. 

Even though Medicaid is a jointly funded government program between the federal government and states, the states are responsible for administering it, and the Social Security Act allows them the flexibility to customize their Medicaid programs through what are referred to as Section 1115 waivers. These waivers require approval from the Secretary of Health and Human Services. They can modify eligibility requirements or forgo provisions of federal law under the condition that the projects support the goals of the Medicaid program.

States first employed Section 1115 waivers to implement work requirements in 2017 under the Trump Administration. During that time, twelve states received approval from HHS. Shortly after, the Trump Administration was sued by health care advocates and civil rights groups, rescinding the work requirement legislation in Arkansas and Kansas. Because of this, other states were also prohibited from implementing their provisions.

GA's Work Requirements

Shortly after President Biden transitioned into office, he reversed a number of other waivers that provided states approval to implement Medicaid work requirements. Georgia was one of the states impacted by the decision and sued the administration. The District Court for the Southern District of Georgia ruled in support of Georgia, citing that the administration did not consider whether reversing the waiver would cause less Medicaid coverage. Georgia has become the only state with a work requirement for Medicaid eligibility, and the state's program, Pathways to Coverage, launched at the beginning of this month.

Work requirements have once again become a topic of debate among health care professionals and government officials. Some view the requirements as barriers to health coverage that go directly against the objectives of the Medicaid program. They argue that Medicaid is designed to provide insurance, not encourage employment. However, work requirement proponents say that the program has grown far beyond its original scope, and states must control costs. At the moment, states are navigating eligibility redeterminations, and it's important that vulnerable populations remain covered. Setting the work requirement debate aside, all states should be looking for ways to improve efficiency and cost avoid in their Medicaid plans.

Discover more. 

JUNE MEDICAID RECAP

Syrtis Solutions distributes a monthly Medicaid news recap to help you stay informed. The monthly roundup highlights 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 developments.

Click this link to open the news.

INCREASED MEDICAID SPENDING AND IMPROPER PAYMENTS

 

According to federal agency data from PaymentAccuracy.gov and the Office of Management and Budget, the federal government spent an estimated $247 billion in improper payments in 2022. The data also revealed that the Department of Health and Human Services' Medicaid program made up the majority of these payments at $80.6 billion. Medicaid has become the largest single budget item on states' budgets, and in order for the program to continue being solvent, states must resolve Medicaid's improper payment problem.

Recently, states have started resuming Medicaid eligibility redeterminations because of the end of the Coronavirus Public Health Emergency continuous enrollment provision. Since June 29th, at least 1,536,000 enrollees have been disenrolled. Some states are expecting the eligibility redeterminations to lower program costs; however, KFF is predicting that it's possible that state Medicaid spending will increase as the enhanced FMAP expires. Medicaid can not afford increased program spending while losing billions in improper payments.

A frequent misunderstanding is that improper payments originate from fraud and abuse when in fact, the vast majority stem from prosaic, mundane issues such as eligibility errors and old data systems. One way Medicaid administrators could decrease improper payments and improve program efficiency immediately is to adopt technology solutions that help identify primary commercial payers in order to avoid making claims payments in error.

Cost Avoid Improper Payments With Quality Data

Health plans have difficulty identifying primary coverage on pharmacy and medical claims because the data they access is not current, available, complete, or accurate. Thus, plans have no choice but to pay claims in error and chase reimbursement once other health insurance (OHI) is found. Unfortunately, for Medicaid plans, the actual monies recovered remain around twenty cents on the dollar.

Syrtis Solutions understood that Medicaid plans needed a method to determine active OHI coverage to adjudicate claims properly. ProTPL, introduced in 2010, is a real-time point-of-sale cost avoidance service for government-funded healthcare programs that delivers powerful, accurate, and actionable eligibility data. The solution gives health plans the ability to cost avoid Rx and medical claims and the associated costs of recovery.

Medicaid's improper payments are costing billions of dollars each year, and program expenditures are climbing. Because of this, states are likely to begin considering trimming benefits. To remain solvent and continue providing care to the most vulnerable populations, Medicaid must strengthen its fiscal oversight of program expenditures and make certain that program resources are spent properly. Presently, the best place to start saving resources and reducing improper payments is to provide Medicaid payers access to clean and actionable eligibility data that they can rely on.

Click here and read more. 

MAY MEDICAID NEWS 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 developments.

Click this link to read the news. 

IMPROPER PAYMENTS KEEP MEDICAID ON GAO'S HIGH-RISK LIST

 

The GAO just recently published its updated High-Risk List. The update is part of the biennial High-Risk Series started in 1990 that identifies government operations susceptible to fraud, waste, abuse, and mismanagement. The current report marks the twentieth consecutive year that Medicaid has made the cut. According to the GAO, CMS must strengthen fiscal oversight of program expenditures to reduce improper claims payments and ensure that program resources are spent correctly.

Fiscal year 2022 was a demanding period for Medicaid as the program was dealing with the ongoing social and financial impact of the COVID-19 Public Health Emergency (PHE). Enrollment increased by almost 20 million people between 2020 and 2022. Consequently, initiatives to strengthen program integrity were often superseded by the necessity to act in response to the PHE and support states. In FY 2022, Medicaid provided close to 82 million beneficiaries with healthcare at an estimated cost of $516 billion.

High-Risk Segments of the Medicaid Program

The GAO's report pinpointed the following three segments that comprise the overall high-risk of the Medicaid program:

1. Improper payments hit $81 billion in FY 2022
2. The use of state-directed payments and supplemental payments
3. Limited oversight of Medicaid expenditures and utilization data

Recommendations from the GAO

Along with identifying segments of high-risk, the GAO's report also endeavors to help resolve these susceptibilities by making recommendations. Currently, seventy recommendations associated with Medicaid program integrity remain open. The GAO's recommendations to CMS for 2023 are:

• Expand its evaluation of states' implementation of provider screening and enrollment requirements and, for states not fully compliant with the requirements, annually monitor their implementation progress;
• improve oversight of Medicaid procurements;
• collect adequate provider-specific information from states on Medicaid payments to providers, including supplemental payments and the sources of funds states use to fund their share of the payments, and specify what criteria should be used to ensure that Medicaid payments at the provider level are economical and efficient;
• perform an assessment and take steps to ensure that resources to oversee state-reported expenditures are sufficient and allocated according to risk; and
• continue efforts to assess and improve T-MSIS data and articulate specific plans and associated time frames for using these data for broad program oversight.

Reduce Improper Claims Payments with True Cost Avoidance

Improper claims payments has been recognized each year by the GAO as a significant factor in Medicaid waste and mismanagement. Improper payments cost the program billions of dollars every year, threatening the program's solvency and sustainability. One way Medicaid administrators could minimize improper payments immediately is to adopt technology solutions that help identify primary commercial payers in order to avoid making claims payments in error.

Health plans have difficulty determining primary coverage on pharmacy and medical claims because the data they access is not current, available, complete, or accurate. Thus, plans have no choice but to pay claims in error and chase reimbursement once other health insurance (OHI) is found. Unfortunately, for Medicaid plans, the actual monies recouped remain around twenty cents on the dollar.

Syrtis Solutions recognized that Medicaid plans needed a way to determine active OHI coverage to adjudicate claims properly. ProTPL, introduced in 2010, is a real-time point of sale cost avoidance service for government funded healthcare programs that delivers powerful, accurate, and actionable eligibility data. The solution gives health plans the ability to cost avoid Rx and medical claims and the associated costs of recovery.

Medicaid has remained on the GAO's High-Risk List since 2003. Throughout the years, the program has struggled with fiscal oversight and integrity. Medicaid's improper payment rate alone is costing billions of dollars each year. To remain solvent, Medicaid must improve its fiscal oversight of program expenditures and ensure that program resources are spent properly. At the moment, the best place to start saving resources and reducing improper payments is to provide Medicaid payers access to clean and actionable eligibility data that they can rely on.

Find out more.