29 Mar MEDICAID IMPROPER PAYMENTS TOTALED $50.3 BILLION IN 2023
A recent audit by the U.S. Government Accountability Office reveals that the government suffered a significant loss of $236 billion in 2023 as a result of improper payments. Medicaid and Medicare alone accounted for 43% of these payments, with Medicaid’s improper payments reaching $50.3 billion. These findings draw attention to the immediate need to deal with improper payments, which frequently come from eligibility errors and out-of-date data systems, not rampant fraud and abuse.
By law, Medicaid functions as the payer of last resort, meaning Medicaid covers healthcare expenses only after other third-party payers fulfill their obligations. Nonetheless, determining these third-party payers has become increasingly difficult as the program expands due to insufficient access to quality eligibility data. The lack of accurate data has led to billions in improper payments for Medicaid plans.
When Medicaid plans discover improperly paid payments, they employ a “pay and chase” process to recoup funds. This approach has produced a multibillion-dollar post-payment recovery industry, but unfortunately, for payers of last resort, only 20 cents on the dollar is recovered.
The challenge to identify liable third-party payers has persisted for years, exacerbated by the lack of technology capable of correctly pinpointing active and accurate OHI. Regardless of legislative efforts and federal initiatives to curb improper payments, the problem has continued, resulting in Medicaid’s inclusion on the Government Accountability Office’s high-risk list for twenty consecutive years.
How can payers of last resort minimize improper payments?
To mitigate the need for post-payment recovery, Medicaid payers must gain access to timely and accurate eligibility data. Leveraging ePrescribing infrastructures presents a promising solution, as they house some of the most complete and current data on patients’ health insurance coverage.
Recognizing this potential, Syrtis Solutions has developed ProTPL, a technology-based solution that utilizes ePrescribing eligibility data to assist Medicaid plans proactively identify primary payers. ProTPL enables Medicaid plans to avoid erroneous claims costs upfront with proprietary logic and advanced matching algorithms, improving the claims process for all stakeholders involved.
Syrtis Solutions’ ProTPL addresses the root cause of improper payments by utilizing better data and applying it to avoid erroneous claims payments. ProTPL ultimately decreases costs and improves efficiency in Medicaid claims management.