30 Nov STATES CHALLENGE WITH MEDICAID IMPROPER PAYMENTS & HIDDEN COMMERCIAL COVERAGE
In 2024, Medicaid improper payments climbed to an estimated $31.1 billion, putting immense strain on state budgets and calling the program’s long-term sustainability into question. A sizable portion of that figure is tied to a familiar but stubborn problem: Medicaid paying for claims that should have been covered by commercial insurance.
At any given time, roughly 10% of Medicaid beneficiaries have some form of commercial coverage that is either unreported or invisible to traditional systems. States rely on legacy coordination of benefits processes that depend on outdated eligibility records, fragmented data sources, and manual or inconsistent verification workflows. When other health insurance isn’t identified up front, Medicaid pays incorrectly. Only afterward do states attempt to recover dollars through pay-and-chase methods that rarely recoup more than a modest fraction of what was lost.
Every one of these improper payments is a preventable diversion of funds away from the people Medicaid is intended to serve. The key to stopping them is simple but difficult to execute: identify other coverage before the claim is paid.
THE BIG BEAUTIFUL BILL: WHY THE PRESSURE IS ABOUT TO INTENSIFY
Federal policy shifts under the Big Beautiful Bill are set to magnify this problem. The legislation tightens Medicaid financing rules, placing new limits on how states structure eligibility, raise revenue, and manage budget gaps. These constraints mean states will have fewer levers to pull when costs rise.
Key dynamics introduced by the Big Beautiful Bill include:
- Stricter eligibility and spending parameters
- Reduced flexibility to generate supplemental revenue
- Heightened tradeoffs between preserving benefits and balancing budgets
In this new environment, cost avoidance moves from a strategic advantage to a survival requirement. States must identify TPL, or they will continue to pay claims that properly belong to commercial insurers, resulting in improper payments.
SYRTIS SOLUTIONS: PREVENTING IMPROPER PAYMENTS AT THE POINT OF SALE
Syrtis Solutions helps Medicaid payers confront this challenge where it matters most—before the claim is paid. Its flagship solution, ProTPL, is a real-time cost-avoidance technology designed to detect previously unknown commercial coverage at the point of sale.
ProTPL leverages exclusive access to the nation’s largest ePrescribing infrastructure to identify primary coverage that traditional third-party liability vendors often miss. Medicaid programs using ProTPL typically uncover around 25% more commercial coverage than with conventional TPL methods. That means fewer claims are paid in error, and far less reliance on slow, resource-intensive recovery efforts.
Because ProTPL prevents the payment from ever leaving the Medicaid program, savings are immediate and durable. Dollars stay where they belong—supporting beneficiaries and strengthening program integrity.
Health plans and state Medicaid agencies choose Syrtis Solutions because:
- Implementation is fast and non-disruptive
- Existing vendors and workflows remain in place
- Federal TPL requirements are easier to meet
- Administrative teams avoid additional workload
ProTPL operates on a transaction-based pricing model and is already trusted by major payers nationwide as a proven way to reduce waste, protect budgets, and stabilize provider networks.
DISCOVER THE SAVINGS YOU’RE MISSING
To help Medicaid payers understand the scope of their opportunity, Syrtis offers a complimentary claims analysis. Using the plan’s own data, this review pinpoints where current processes are failing to identify other coverage and quantifies the impact in real dollars.
The analysis often reveals:
- Claims that should have been billed to commercial plans
- Gaps in eligibility and coverage detection workflows
- Concrete, actionable savings opportunities
For Medicaid programs operating under increasing fiscal pressure, gaining this level of visibility early can shape better policy decisions, improve short-term financial performance, and support long-term program sustainability.