29 Mar MEDICAID IMPROPER PAYMENTS REACHED $50.3 BILLION IN ’23
A new audit by the GAO indicates 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findings highlight the critical need to deal with improper payments, which regularly come from eligibility errors and out-of-date data systems, not widespread fraud and abuse.
By law, the Medicaid program operates as the payer of last resort, meaning it covers healthcare costs only after other third-party payers satisfy their obligations. Nevertheless, detecting these third-party payers has become more and more difficult as the program expands because of insufficient access to high quality eligibility data. The lack of accurate data has resulted in billions in improper payments for Medicaid plans.
Whenever Medicaid plans identify improperly paid payments, they use a “pay and chase” procedure to recoup funds. This approach has created 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 decades, exacerbated by the lack of technology capable of accurately pinpointing active and accurate OHI. In spite of legislative efforts and federal actions to control improper payments, the problem has persisted, resulting in Medicaid’s inclusion on the Government Accountability Office’s high-risk list for twenty consecutive years.
How can payers of last resort mitigate 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 created ProTPL, a technology-based solution that utilizes ePrescribing eligibility data to help 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 harnessing better data and applying it to prevent erroneous claims payments. ProTPL ultimately decreases costs and improves efficiency in Medicaid claims management.