30 May STATES ADDRESS RISING MEDICAID COSTS THROUGH REFORM AND TECHNOLOGY
Medicaid, the largest public health insurance program in the United States, is under scrutiny, not for its mission, but for its costs. What started as a vital safety net has grown into a massive budget line item for nearly every state. With Medicaid now accounting for nearly a third of many state budgets, policymakers are facing a difficult question: how do we preserve access while reducing inefficiencies?
Pandemic-era protections and expansion policies led to the most significant enrollment surge in the program’s history. While millions gained coverage, the long-term price tag is proving challenging for states to manage, especially given the ongoing debate over budget cuts. Now, many are taking a hard look at how Medicaid dollars are spent—and more importantly, how to stop the waste.
A BILLION-DOLLAR PROBLEM HIDING IN PLAIN SIGHT
One of Medicaid’s most significant financial leaks is due to improper payments. In fiscal year 2023 alone, the Centers for Medicare & Medicaid Services (CMS) reported more than $50 billion in payments made in error. And this isn’t new—over the past decade, more than $543 billion in improper payments have been documented.
The issue isn’t always fraud—it’s often about gaps in documentation or eligibility verification. Still, the outcome remains the same: precious healthcare funds are being misdirected, creating unnecessary strain on already tight budgets.
STATES STEP UP WITH STRUCTURAL REFORMS
Faced with rising costs, several states are launching reforms designed to make Medicaid more accurate, efficient, and sustainable:
- Indiana is requiring cross-checks of applicant data with state and federal systems, ending self-attestation, and mandating transparency on improper payments.
- Texas has adopted technology to verify income and coverage through third-party data sources, helping confirm eligibility automatically.
- Florida and Missouri are requiring frequent redeterminations of eligibility and tightening oversight of managed care providers.
- Arkansas and Georgia have reintroduced strict eligibility review processes and use data to flag and remove ineligible enrollees.
States are signaling that they’re serious about accountability—and ready to challenge the outdated systems that have allowed these issues to persist.
TECHNOLOGY TAKES CENTER STAGE IN MODERNIZATION EFFORTS
But policy alone won’t fix the problem. To truly improve Medicaid’s claims payment accuracy and reduce unnecessary costs, states need modern tools that work in real time.
That’s where technology like ProTPL from Syrtis Solutions is changing the game.
ProTPL is an automated third-party liability (TPL) solution that helps Medicaid plans ensure they’re not paying for claims that should be covered by private insurance. With ProTPL, plans can:
- Detect commercial insurance coverage before claims are paid,
- Avoid improper payments on both pharmacy and medical services,
- Reduce manual processes and free up administrative resources,
- Comply with federal cost avoidance regulations more efficiently.
By shifting to a proactive model—preventing payments instead of recovering them later—states and Medicaid plans can regain control of their healthcare spending.
SMART POLICY + SMART TECH = A SUSTAINABLE FUTURE
How Medicaid is managed must evolve. States that take a dual approach—implementing meaningful reforms while adopting scalable technology—are better positioned to maintain the integrity of the program without sacrificing service. In the face of growing costs, it’s clear that the combination of real-time oversight, improved data, and more innovative tools like ProTPL can help states stretch every Medicaid dollar further, protect taxpayer funds, and focus resources on those who truly need them.