Syrtis Solutions

Drug pricing reform has become a central focus in the effort to control Medicaid spending. As states confront rising healthcare costs, growing enrollment, increased utilization of specialty medications, and mounting program complexity, policymakers continue searching for strategies that can reduce expenditures while preserving access to care. Federal initiatives such as CMS's GENEROUS Model reflect this growing emphasis on pharmaceutical cost containment, but they also underscore a larger reality: meaningful Medicaid savings require a broader approach that extends beyond drug pricing alone.

For Medicaid agencies and managed care organizations, some of the most significant savings opportunities are not tied to future legislation, manufacturer negotiations, or demonstration projects. They stem from improving payment accuracy before claims are paid.

The Problem Isn't Always What Medicaid Pays—It's When Medicaid Pays

Much of the national conversation centers on reducing the price of healthcare services and prescription drugs. Yet a considerable portion of Medicaid's financial leakage occurs for a different reason entirely.

Claims are often paid using incomplete, outdated, or inaccurate coverage information. When Medicaid lacks visibility into a beneficiary's current insurance status, the program may incorrectly pay claims that should have been billed to another payer first.

In these situations, the issue is not necessarily the cost of the service itself. The issue is that Medicaid paid when another insurer had primary responsibility. As long as these coverage gaps exist, payment errors will continue regardless of future pricing reforms.

Unknown Coverage Remains a Persistent Challenge

Medicaid operates within one of the most dynamic eligibility environments in healthcare. Beneficiaries routinely experience changes that can affect insurance status throughout the year, including:

New employment

Employer-sponsored coverage enrollment

Marriage or dependent coverage changes

Loss of commercial insurance

Medicaid redeterminations

Movement between public and private coverage

These changes often occur faster than eligibility systems can capture them.

As a result, there is frequently a disconnect between a beneficiary's actual coverage status and the information available to Medicaid when a claim is adjudicated. During this period, claims may be processed without identifying existing commercial coverage or other third-party liability resources.

The outcome is avoidable spending that accumulates claim by claim across the program.

Why Recovery Alone Cannot Solve the Problem

Historically, many organizations have relied heavily on post-payment recovery activities to identify and recoup funds after improper payments occur.

Recovery efforts remain valuable and should continue to play an important role in a comprehensive program integrity strategy. However, recovering dollars after payment is fundamentally different from preventing those payments in the first place.

Once a claim has been paid incorrectly, administrative resources must be devoted to identifying the error, pursuing repayment, managing provider communications, and reconciling financial records.

More importantly, the improper payment has already occurred.

From a program integrity perspective, prevention delivers benefits that recovery simply cannot replicate. Stopping an incorrect payment before adjudication eliminates the need for downstream recovery activity while improving overall payment accuracy.

The Value of Better Eligibility and TPL Data

Effective cost avoidance begins with visibility. When Medicaid programs have access to more timely and accurate eligibility information, they can identify commercial coverage sooner, maintain more reliable third-party liability records, and coordinate benefits more effectively. This allows claims to be routed correctly before payment occurs rather than being corrected afterward.

Improved eligibility and TPL data support:

Earlier identification of commercial insurance

Stronger coordination of benefits processes

Reduced improper payments

Lower administrative recovery costs

Improved payment accuracy

Enhanced compliance and program integrity performance

Unlike many large-scale policy initiatives, these improvements can be implemented today and can begin generating results immediately.

Drug Pricing Reform and Payment Prevention Serve Different Purposes

Drug pricing reform and payment prevention should not be viewed as competing approaches. Both have value. Programs such as the GENEROUS Model seek to reduce the amount Medicaid pays for certain medications. Payment prevention focuses on ensuring Medicaid only pays claims for which it is actually responsible. One strategy addresses price. The other addresses payment accuracy.

Even substantial reductions in pharmaceutical costs cannot eliminate spending associated with unidentified commercial coverage, coordination of benefits failures, or inaccurate eligibility information. Likewise, improving payment accuracy does not diminish the importance of pursuing lower healthcare costs.

The strongest financial outcomes occur when both approaches operate together.

A More Immediate Path to Savings

While policymakers continue evaluating long-term reforms, Medicaid agencies and managed care organizations already possess an opportunity to improve financial performance through better data, stronger eligibility processes, and proactive identification of third-party liability.

The technology, analytics, and operational tools necessary to support these efforts are available today.

Rather than waiting years for policy changes to mature, organizations can begin reducing avoidable expenditures immediately by improving visibility into coverage and preventing claims from being paid incorrectly.

Drug pricing reform may ultimately reduce spending in certain areas of Medicaid, but it cannot address every source of financial leakage within the program. Some of the largest and most immediate savings opportunities stem from improving eligibility accuracy, identifying third-party liability sooner, strengthening coordination of benefits, and preventing improper payments before they occur. While policymakers continue pursuing long-term pricing initiatives, Medicaid agencies and managed care organizations can improve program integrity and generate measurable savings today by ensuring claims are paid the first time correctly.

Each month, Syrtis Solutions provides a curated Medicaid news roundup to help readers stay current on important industry developments. The summary focuses on policy updates, research, and legislative activity impacting Medicaid program integrity, cost avoidance strategies, coordination of benefits, and efforts to reduce improper payments and fraud. Below is a look at last month’s Medicaid news highlights.

Stephen Konsin Jr. from Syrtis Solutions, a solution provider at the Marcus Evans Value-Based Care Summit 2026, discusses the growing need for proactive Medicaid payment accuracy and cost avoidance strategies.

Interview with: Stephen Konsin Jr., Vice President of Sales, Syrtis Solutions

“The window for demonstrating proactive prevention of improper payments before the 2030 mandatory Federal Medical Assistance Percentage (FMAP) reductions is narrowing with each fiscal quarter. Organizations that act now will be positioning themselves to meet federal compliance expectations while realizing multi-year operational benefits. Those that delay it will have limited time to demonstrate sustained improvement trends, reducing options for mitigating FMAP consequences,” says Stephen Konsin Jr., Vice President of Sales, Syrtis Solutions.

Syrtis Solutions is a solution provider at the Marcus Evans Value-Based Care Summit 2026.

What is changing with the One Big Beautiful Bill Act? What do healthcare leaders need to plan for?

The One Big Beautiful Bill Act (H.R. 1) converts improper payment performance from a compliance benchmark into a direct funding trigger. Beginning in FY2030, states will face mandatory FMAP reductions when Medicaid improper payment rates exceed three percent. This represents a paradigm shift from discretionary oversight to automatic financial penalties, with only limited waiver authority available to states demonstrating good-faith corrective action. FMAP reductions are triggered by error rates at adjudication, not by net financial impact after recovery efforts.

For healthcare organizations, unknown primary commercial insurance coverage represents a significant preventable category of improper Medicaid payments. When beneficiaries have unreported or recently activated commercial insurance, Medicaid systems lack real-time visibility at claim adjudication. Traditional third-party (TPL) liability infrastructure cannot close this gap. TPL programs mostly rely on member self-disclosure, delayed batch feeds, and periodic data matching that structurally miss coverage changes between verification cycles. What was improper at adjudication remains improper in Payment Error Rate Measurement (PERM) calculations regardless of later corrective action.

Why is the compliance clock ticking? What strategies could they implement to reduce improper payments before they occur?

We address this structural constraint through real-time access to nationwide commercial payer eligibility data. The platform verifies primary coverage by identifying previously unknown commercial insurance, enabling prevention before Medicaid payment occurs. This directly addresses the compliance metric triggering FMAP reductions. For Medicaid agencies and managed care organizations facing mandatory FMAP consequences, the compliance timeline is compressed. Organizations implementing real-time prevention capabilities now can demonstrate multi-year improvement trends before 2030 consequences take effect, thus creating the operational track record that limited waiver authority requires.

The FY2030 FMAP reduction mandate transforms prevention from operational “best practice” to fiscal imperative. States can no longer rely on recovery performance to manage TPL compliance. The PERM methodology measures error rates at adjudication, creating permanent advantages for prevention approaches that stop improper payments before they occur. Recovery programs remain necessary components of comprehensive TPL operations, addressing improper payments that evade prevention systems and managing historical claims. However, recovery alone cannot achieve FMAP compliance when error rates exceed three percent. Only prevention capabilities that reduce gross improper payment rates can protect federal medical assistance funds under the One Big Beautiful Bill Act requirements.

Why can’t traditional approaches solve this?

The fundamental constraint is data availability at the time of claims payment. The traditional pay-and-chase model is a rational response to ensure beneficiary access through prompt payment. However, this model cannot prevent FMAP reductions as it addresses errors after they occur.

Prospective prevention eliminates improper claims payments before occurrence by verifying coverage at payment decision and routing all future claims appropriately. A claim correctly routed to commercial insurance never appears as an improper Medicaid payment in PERM audits. It requires no identification, investigation, recovery or reconciliation. It creates no provider friction, member confusion or administrative burden. Cost avoidance is permanent and the improper payment never exists. This is not incremental improvement to recovery but a structural shift from retrospective correction to prospective prevention.

Does it work with their existing infrastructure?

Syrtis does not replace disclosed coverage already captured in eligibility systems, traditional carrier feeds or batch matching processes. It supplements existing infrastructure by addressing the specific gap those systems structurally cannot close. It identifies commercial coverage never disclosed to the state, coverage that changed since the last data match and coverage resulting from recent life events not yet in batch systems. Typical deployments reach full operational status within three months of project initiation, well within the window needed to begin building a measurable compliance track record before 2030 consequences take effect. The platform is designed to minimize implementation risk while maximizing operational resilience.

Any final thoughts?

In an environment where FMAP protection depends on preventing improper payments rather than recovering them afterward, the difference between prevention and recovery is the difference between maintaining federal matching funds and facing mandatory reductions compounding with every fiscal year.

Federal auditors will increasingly differentiate between programs that have embedded real-time prevention into operations versus those reliant on retrospective correction. The operational track record of implementing real-time verification in 2026, processing millions of claims over subsequent years, and identifying thousands of previously unknown commercial policies with measurable TPL-related improper rate declines presents a fundamentally different compliance profile than maintaining robust recovery while continuing payment without real-time verification.

Contact: Sarin Kouyoumdjian-Gurunlian, Press Manager, Marcus Evans, Summits Division, [email protected]

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About the Value-Based Care Summit 2026

The Value-Based Care Summit aims to foster innovative thinking, share inspiring ideas, and promote community connections. Our continuing mission is to curate an engaging program featuring visionary keynote presentations, real-life case studies and interactive forums delivered by compelling speakers and expert moderators. To achieve this vision we choose our collaborators with great precision – we seek out professionals who have deep expertise and hands-on experience, and can present cutting-edge insights that spark conversation.

About Syrtis Solutions

Syrtis Solutions was founded in 2011 after seeing payers of last resort – Medicaid, Medicare and Marketplace plans – struggle to properly identify third-party liability (TPL) information quickly and accurately. Still today, health plans rely on stale data mined from millions of other health insurance (OHI) coverage records that are incomplete, often expired, and frequently for the wrong member. This poor-quality data leads to member disruption and provider abrasion at the pharmacy counter, OHI overrides, and claims paid in error which fuels ineffective “pay and chase” recovery solutions – returning less than 17% of dollars attempted for recovery.

Today, we are helping solve this problem for health plans – looking for OHI on 42% of the Medicaid managed care lives covered by 83 different health plans. If you are looking for a better OHI discovery solution that reduces your reliance on “pay and chase” efforts – we invite you to meet with us. With as few as 5,000 member records, we can show you the opportunities you are missing and the quality of your current OHI data. Within just a few weeks, you will see your OHI cost avoidance efforts increase due to better quality OHI data, and we bet you will see less OHI override calls to your member services and pharmacy help desk as well!

www.syrtis.com

About Marcus Evans Summits

Marcus Evans Summits are high level business forums for the world’s leading decision-makers to meet, learn and discuss strategies and solutions. Held at exclusive locations around the world, these events provide attendees with a unique opportunity to individually tailor their schedules of keynote presentations, case studies, roundtables and one-on-one business meetings. For more information, please visit www.marcusevans.com

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To help Medicaid stakeholders stay informed, Syrtis Solutions distributes a monthly Medicaid news digest covering major developments across the Medicaid landscape. The roundup emphasizes topics such as program integrity, cost avoidance, coordination of benefits, improper payments, and fraud prevention. Below is a summary of the most important Medicaid news from the past month.

Medicaid plays a foundational role in the U.S. healthcare system, providing essential coverage to tens of millions of Americans, including low-income families, seniors, and individuals with disabilities. As enrollment and program responsibilities have expanded, so has the importance of ensuring that Medicaid dollars are spent accurately and efficiently. However, fraud, abuse, and systemic inefficiencies continue to divert significant funding away from patient care each year.

Fraud—defined as the intentional misrepresentation of information to obtain unauthorized payments—remains a serious concern within Medicaid. Many cases involve providers submitting claims for services that were never delivered or exaggerating the scope of care provided. While these instances draw attention, they represent only one part of a much larger issue. The majority of improper payments are driven not by intentional wrongdoing, but by breakdowns in administrative processes, such as incomplete documentation, outdated eligibility records, and limited coordination across payers.

At the core of the problem is the complexity of Medicaid’s operating environment. Eligibility is fluid, often changing due to employment shifts, income fluctuations, or changes in household composition. At the same time, beneficiaries may have access to other forms of insurance coverage that are not always identified in real time. When Medicaid systems lack up-to-date or comprehensive information, they are forced to make payment decisions with partial visibility—creating conditions where errors are far more likely.

This challenge is amplified by the program’s historical infrastructure. Medicaid’s administrative systems were developed decades ago, when the program served a smaller population and operated with far fewer variables. Processes were designed around periodic eligibility checks, self-reported information, and delayed data exchanges. While the healthcare landscape has evolved dramatically, many of these underlying systems have not kept pace.

Today, Medicaid must manage a far more complex set of responsibilities, including coordinating benefits across multiple payers and supporting diverse care models. Yet many states continue to rely on data that may be weeks or months out of date, particularly when it comes to eligibility status and third-party liability information. These delays create critical gaps at the point of care and claim adjudication—precisely when accurate, real-time information is most needed.

The financial consequences are substantial. Improper payments reduce the funds available to deliver care, placing additional strain on already constrained state budgets. Over time, these losses can limit program flexibility, increase exposure to federal penalties or oversight, and force difficult decisions about resource allocation. Essential services may be disproportionately affected when funding becomes constrained.

Historically, Medicaid integrity efforts have focused on identifying and recovering improper payments after they occur. Audits, investigations, and post-payment reviews have been valuable tools in addressing vulnerabilities and holding bad actors accountable. However, as the scale and complexity of the program continue to grow, this retrospective approach is becoming increasingly insufficient. Recovering funds after the fact is costly, time-consuming, and labor-intensive.

A more sustainable strategy centers on prevention. By improving data accuracy and enabling real-time visibility into eligibility and other coverage, Medicaid programs can reduce the likelihood of improper payments before they happen. Modern solutions that integrate data sources and verify coverage at the point of adjudication offer a way to enhance both efficiency and accuracy, while reducing administrative burden.

Addressing fraud, abuse, and inefficiency in Medicaid ultimately requires a shift in mindset—from reactive recovery to proactive prevention. Ensuring that payments are made correctly the first time not only protects public resources but also strengthens the program’s ability to serve those who rely on it most.

As Medicaid continues to evolve, aligning its operational capabilities with its current scale and complexity will be critical. Without that alignment, even well-intentioned oversight efforts will struggle to keep pace, leaving persistent gaps that undermine both financial integrity and access to care.

Syrtis Solutions shares a monthly Medicaid news brief that tracks the latest policy, research, and industry developments affecting Medicaid programs. Topics include program integrity, cost avoidance initiatives, coordination of benefits, improper payment reduction, and fraud, waste, and abuse oversight. The following section summarizes last month’s Medicaid news.

Medicaid leaders oversee one of the largest and most complex public programs in the country. Every day, state agencies and managed care organizations determine eligibility, process high volumes of medical and pharmacy claims, and coordinate care for millions of beneficiaries. With joint federal–state spending reaching into the hundreds of billions of dollars annually—and with growing fiscal pressure on state budgets—the importance of payment accuracy has never been greater.

Program integrity is not about casting suspicion. It is about precision. It ensures that Medicaid dollars are spent correctly, that eligible individuals receive uninterrupted care, and that public resources are preserved for those who depend on them most. When integrity systems function effectively, administrative friction decreases, provider relationships improve, and public trust strengthens.

What Program Integrity Really Means

At its core, Medicaid program integrity is the ability to carry out the program’s mission—delivering high-quality, accessible healthcare to vulnerable populations—without being compromised by preventable errors or inefficiencies. It reflects a system’s capacity to pay claims accurately while maintaining streamlined access for beneficiaries.

Improper payment rates are the primary federal metric used to evaluate payment quality. Importantly, improper payments are not synonymous with fraud. Most stem from technical errors, documentation gaps, or eligibility verification challenges rather than intentional misuse.

Medicaid’s complexity contributes to these challenges. Frequent eligibility redeterminations, income fluctuations, household composition changes, citizenship verification requirements, third-party liability coordination, and provider enrollment rules all introduce administrative risk points. In fact, recent federal findings indicate that a substantial majority of improper payments result from missing documentation or incomplete administrative steps—not malicious activity.

In 2025 alone, 77.2% of improper Medicaid payments resulted from insufficient documentation or missing administrative steps.

The reality is that many agencies are working diligently to pay correctly but are constrained by legacy technology, fragmented data, and delayed information feeds. The opportunity lies in equipping programs with tools that prevent errors before they occur.

Three Strategic Levers to Improve Payment Accuracy

State Medicaid agencies and managed care plans have several proven pathways to strengthen integrity.

1. Enhanced Data Sharing

Secure, verified data exchange reduces reliance on self-reported information and minimizes avoidable mistakes. Real-time cross-checks with federal and state partners—such as the Social Security Administration and other trusted sources—can prevent payments to ineligible individuals and flag discrepancies early.

When states expand consent-based data exchanges and automate verification processes, they consistently report measurable reductions in error rates without increasing applicant burden.

2. Modernized Technology Infrastructure

Many Medicaid systems still operate on decades-old platforms designed for far simpler eligibility environments. Modern IT architecture allows agencies to:

Automate eligibility cross-checks

Validate coverage in near real time

Track provider enrollment more effectively

Improve audit transparency and reporting

Investment in flexible, standards-based systems yields operational dividends—improving both payment precision and staff productivity.

A leading example in the area of third-party liability (TPL) prevention is Syrtis Solutions and its ProTPL platform.

ProTPL is designed specifically for payers of last resort. Through a nationwide Master Patient Index representing more than 300 million covered lives, the platform conducts industry-standard electronic transactions to detect active commercial Other Health Insurance (OHI) at the point of adjudication.

Rather than relying on outdated batch files, 834 feeds, or self-disclosed coverage, ProTPL identifies active commercial coverage in near real time—before Medicaid pays the claim. Users report significant increases in OHI discovery compared to traditional TPL workflows.

The operational impact is substantial:

Improper claims are avoided upfront

Administrative recovery efforts are reduced

Compliance with federal TPL requirements is strengthened

Medicaid maintains its role as payer of last resort

By shifting from reactive “pay-and-chase” recovery—where only a fraction of dollars are typically recovered—to prospective cost avoidance, states preserve millions in resources that can be redirected to core beneficiary services.

3. AI and Intelligent Automation

Artificial intelligence and automation are increasingly being deployed to streamline routine tasks. These tools can:

Flag potential eligibility mismatches

Prioritize higher-risk claims for manual review

Accelerate provider enrollment validation

Identify emerging error patterns

When implemented with appropriate oversight and governance, automation enhances speed and precision while allowing experienced staff to focus on complex cases and member support.

Balancing Integrity and Access

A frequent concern is that stronger oversight could create barriers for eligible families. In practice, the opposite occurs when improvements are implemented thoughtfully.

Preventing errors early reduces downstream disruptions—such as claim reversals, beneficiary appeals, and provider recoupments—that create confusion and administrative burden. When programs operate with cleaner data and stronger verification systems, beneficiaries experience fewer interruptions, and providers face fewer retroactive adjustments.

The savings generated from improved payment accuracy can be reinvested in:

Streamlined enrollment pathways

Faster claims adjudication

Enhanced outreach efforts

Improved member services

Integrity and access are not competing priorities. When aligned properly, they reinforce one another.

Why the Moment Demands Action

As federal deficits and state budget pressures continue, even modest improvements in improper payment rates translate into meaningful financial protection. A single percentage-point reduction can represent tens of millions of dollars for mid-sized states—and significantly more for larger programs.

Beyond fiscal stewardship, credible integrity programs protect public confidence. Taxpayers expect that Medicaid funds are directed appropriately. Legislators expect measurable accountability. Providers expect clear rules. Beneficiaries expect uninterrupted access.

State Medicaid leaders are uniquely positioned to advance this work. By prioritizing data-driven verification, upgrading legacy systems, and deploying targeted cost-avoidance technologies, agencies can transform integrity from a compliance obligation into an operational advantage.

Moving Forward

Medicaid integrity should not be viewed as a regulatory requirement to manage—it should be embraced as a strategic capability that strengthens the entire program.

Investing in modern data connectivity, real-time coverage validation, and intelligent automation enables agencies to:

Reduce preventable improper payments

Lower administrative recovery costs

Strengthen compliance performance

Preserve resources for essential services

Strong program integrity ultimately protects what matters most: reliable healthcare coverage for millions of individuals and families who depend on Medicaid every day.

The path forward is clear. Precision at the point of payment is not only achievable—it is essential for the future sustainability of Medicaid.

Our monthly Medicaid news brief highlights the latest developments shaping program integrity and financial compliance. This summary captures key updates from the past month across legislation, research, and enforcement activity.

As states begin developing fiscal year (FY) 2027 budgets, Medicaid programs are operating in a more constrained financial environment. Revenue growth has slowed, healthcare costs continue to rise, and federal policy changes enacted through the 2025 budget reconciliation law have added new uncertainty around future funding. Even with enrollment leveling off, spending pressures remain intense, driven by higher-need populations, increased utilization of long-term services and supports, rising pharmacy costs, and expanding behavioral health demand.

In response, many states are revisiting traditional cost-containment options. Discussions around provider rate adjustments, limits on optional benefits, and other short-term budget controls are becoming more common. While these approaches can deliver immediate relief, they often carry unintended consequences—restricted access to care, provider instability, and outcomes that conflict with CMS’s broader goals of coverage continuity and population health. As fiscal pressures mount, states and Medicaid managed care organizations (MCOs) are being forced to rethink how savings are generated and whether benefit reductions are a sustainable solution.

Heightened Consequences for Payment Errors

At the same time, Medicaid payment accuracy has become a focus of federal oversight. Improper payments exceeding the 3 percent federal benchmark now result in direct financial consequences, regardless of whether those dollars are eventually recovered. States that exceed the threshold face reductions in federal funding, with far fewer opportunities for exemptions than in the past.

This policy shift represents a fundamental change in risk management. Under the current framework, recovering funds after payment no longer protects states from financial exposure. A payment made incorrectly remains improper even if it is later recouped, requiring states to prioritize prevention rather than post-payment recovery.

Preventing Errors Before They Occur

A significant portion of Medicaid improper payments stem from claims that should have been covered by another insurer. Traditional recovery-based strategies address these issues only after the fact, offering limited impact on improper payment rates and no protection against future penalties.

Prospective cost avoidance addresses the issue upstream. Real-time identification of other health insurance and third-party liability ensures Medicaid consistently pays only when it is truly responsible. Each prevented improper payment helps states remain below the 3 percent threshold and protects federal funding for essential services.

Efficiency as a Cost-Containment Strategy

Administrative inefficiencies often magnify budget challenges. Manual workflows, fragmented eligibility systems, and delayed coverage verification increase error rates while adding operational expense.

Automating eligibility checks, claims review, and coverage validation reduces both administrative burden and financial risk. These efficiencies allow Medicaid agencies and MCOs to meet federal accuracy standards without shifting costs onto providers or members.

Program Integrity as Budget Protection

Program integrity has evolved into a critical fiscal safeguard. Proactive oversight, continuous monitoring, and advanced analytics allow states to identify vulnerabilities earlier and prevent recurring payment errors.

When integrated with real-time cost avoidance, program integrity efforts reduce financial leakage, strengthen audit preparedness, and support long-term budget stability—even during periods of economic uncertainty.

A Sustainable Alternative to Benefit Cuts

As Medicaid budgets face increasing strain, reducing benefits should not be the default response. The best way to manage fiscal pressure is to ensure claims are paid correctly the first time.

By preventing improper payments, maintaining compliance with the 3 percent federal standard, and modernizing operational infrastructure, states and Medicaid plans can preserve access to care while protecting limited program resources. In today’s environment, effective cost avoidance is not optional—it is foundational to Medicaid’s financial sustainability.

The Syrtis Solutions Annual Medicaid Review summarizes the most important Medicaid developments of 2025. This year-end report examines integrity initiatives, legislative trends, and strategies addressing cost avoidance, COB, TPL, and fraud prevention.

Stay current with Syrtis Solutions’ monthly Medicaid news digest! Each month, we provide a comprehensive update on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to reduce fraud, waste, and abuse. Our roundup highlights critical policy shifts, legislative developments, and research findings that impact the Medicaid landscape. Here’s a look at last month’s key…

Stay informed with Syrtis Solutions’ monthly Medicaid news update! Each month, we deliver key insights on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to tackle improper payments, fraud, waste, and abuse. Our roundup highlights critical policy changes, research findings, and legislative updates shaping the Medicaid landscape. Here’s a recap of last month’s top Medicaid news.

Stay ahead with Syrtis Solutions' monthly Medicaid news summary! Each month, we bring you the latest updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to prevent improper payments, fraud, waste, and abuse. Our roundup covers essential policy changes, research insights, and legislative developments shaping the Medicaid landscape. Here’s a recap of last month’s top Medicaid news.

Medicaid’s financial landscape grew significantly more fragile in 2024 as Medicaid improper payments climbed to $31.1 billion. This mounting loss is not only a budgetary concern—it directly undermines the program’s ability to deliver care to the people who rely on it. Much of this waste comes from claims Medicaid should not be paying at all. When commercial insurance exists but goes unreported or undetected, Medicaid becomes the unintended payer of last resort.

Today, an estimated one in ten Medicaid members has commercial coverage that state systems cannot identify through traditional methods. Outdated data sources, aging technology, and inconsistent eligibility verification create blind spots that allow these claims to slip through. Once paid, states must turn to inefficient recovery processes that rarely reclaim more than a small fraction of what was lost. Every dollar spent incorrectly diverts resources away from high-priority needs—and nearly all of these payments could be prevented if other coverage were discovered in real time.

THE BIG BEAUTIFUL BILL: WHY THE URGENCY IS INCREASING

The upcoming implementation of the Big Beautiful Bill will amplify the financial pressure already facing Medicaid programs. The legislation introduces new restrictions on how states can manage Medicaid funding, including stricter eligibility constraints, limitations on revenue generation, and a tightening of overall financing flexibility. These shifts will force states into challenging tradeoffs—either increase funding from limited revenue sources or reduce essential services to balance their budgets.

As these pressures intensify, the value of cost avoidance becomes unmistakable. Ensuring Medicaid pays only after all other responsible insurers have been billed is not just good stewardship—it is a critical requirement for maintaining program stability.

HOW SYRTIS SOLUTIONS STOPS WASTE BEFORE IT HAPPENS

Syrtis Solutions provides Medicaid programs with a powerful way to prevent improper payments at the source. ProTPL, the company’s real-time cost-avoidance technology, identifies unknown commercial coverage before a claim is paid. By tapping into the country’s largest ePrescribing infrastructure, ProTPL reveals primary coverage that traditional third-party liability vendors routinely miss.

Health plans that adopt ProTPL consistently discover far more commercial coverage—often 25 percent more than legacy processes—and dramatically reduce their reliance on slow, costly pay-and-chase recovery efforts. This proactive approach keeps dollars within the Medicaid program, yielding immediate savings and long-term financial protection.

ProTPL is simple to implement, requires no operational overhaul, and supports federal TPL requirements without adding administrative burden. It complements existing vendors, uses a transparent transaction-based pricing structure, and is trusted by major health plans nationwide. For states confronting rising improper payments, eligibility volatility, and new federal financing constraints, ProTPL offers a reliable path to protecting budgets, preserving access, and strengthening program integrity.

SEE EXACTLY WHAT YOU COULD BE SAVING

To help Medicaid payers evaluate their current exposure, Syrtis provides a complimentary claims analysis using the plan’s own data. This review uncovers gaps in existing TPL processes and quantifies where preventable spending is occurring. The insights produced often reveal savings opportunities that would otherwise remain hidden.

For Medicaid programs under tightening financial pressure, gaining this visibility early can influence both short-term decision-making and long-term strategic planning—ultimately improving the sustainability of the program itself.

Stay informed with Syrtis Solutions’ monthly Medicaid news update! Each month, we deliver key insights on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to tackle improper payments, fraud, waste, and abuse. Our roundup highlights critical policy changes, research findings, and legislative updates shaping the Medicaid landscape. Here’s a recap of last month’s top Medicaid news.

Medicaid COB represents one of the most effective strategies available to states seeking to balance budgets without diminishing member benefits. As the Medicare Rights Center notes, states are already taking drastic measures: North Carolina is reducing provider reimbursements, and Nevada’s Medicaid costs consume roughly 25 percent of the state’s total budget. With projected federal cuts of $1…

Cost avoidance through Medicaid COB has become one of the most effective strategies for protecting state Medicaid programs from growing fiscal pressure. Across the nation, states are confronting rising healthcare costs and tightening budgets. The Medicare Rights Center reports that several states have already reduced provider reimbursements and scaled back optional services. At the same time, federal projections indicate that Medicaid funding could decline by $1 trillion over the next decade. Faced with this financial reality, states must identify more effective ways to manage costs without compromising coverage or quality. Strengthening coordination of benefits (COB) and third-party liability (TPL) processes provides a proven, data-driven solution — one that prevents waste, enhances payment accuracy, and preserves access to care while ensuring long-term program integrity.

One of the most significant drivers of waste and inefficiency is the persistent problem of improper payments. As a result of these payments, billions of dollars each year are spent on claims that should have been covered by other payers. Medicaid is meant to pay last, but incomplete or outdated coverage data leads to costly errors.

The old “pay and chase” model attempts to recoup funds after payment, but the yield is small and the process cumbersome. True savings come from preventing the error altogether. That’s why states and MCOs are turning to ProTPL, Syrtis Solutions’ real-time COB and TPL technology. ProTPL identifies other active insurance coverage before claims are paid, ensuring Medicaid dollars are spent only when appropriate.

This proactive approach does more than improve payment accuracy—it strengthens accountability and frees resources for direct patient care. With improper payments representing over $31 billion in annual losses according to CMS, the potential impact is enormous. Nearly 80 percent of these errors result from documentation issues, not fraud. That means they are preventable through better data and smarter systems.

Real-time Medicaid COB transforms this challenge into an opportunity. By integrating advanced analytics and multi-payer data, states can ensure that every claim is properly coordinated. Instead of reacting to waste, they can eliminate it before it happens. The result is a stronger, more sustainable Medicaid program that preserves coverage and improves financial stewardship.

At Syrtis Solutions, our mission is to empower states and managed care organizations with the technology to do just that. ProTPL helps shift Medicaid from reactive recovery toward proactive prevention. As budgets tighten, states must focus on solutions that achieve savings without cutting services. Medicaid COB provides a proven, technology-driven way to achieve that goal—protecting members, reducing waste, and preserving the long-term stability of one of America’s most vital healthcare programs.