#syrtis solutions

Automated algorithmic analysis and insurance discovery engines (AAAIDE) are becoming cornerstones of modern Medicaid operations. By identifying liable third-party coverage at the point of claim adjudication, these technologies reduce improper payments, strengthen payment accuracy, and improve coordination of benefits.

This priority is now reflected in state policy. On June 10, 2026, Ohio passed Senate Bill 315, which requires the Ohio Department of Medicaid to use automated algorithmic analysis and insurance discovery engines before making any Medicaid payment. The measure reflects a broader regulatory shift toward prevention over post-payment recovery.

Under the One Big Beautiful Bill Act (HR1), states must maintain improper payment rates below 3% by federal fiscal year 2030, measured through PERM audits that flag claims where Medicaid was billed as primary despite active third-party coverage. Critically, PERM audits measure compliance at the point of adjudication: once a claim is paid improperly, recovery cannot reverse the improper payment designation. Only point-of-claim insurance discovery prevents both the improper payment and the HR1 compliance risk simultaneously. Traditional post-payment recovery addresses cost but not compliance.

Long before this legislative requirement, Syrtis Solutions was delivering these capabilities to Medicaid managed care organizations nationwide. ProTPL, Syrtis' proprietary platform, continuously analyzes claim-level eligibility and coverage data to identify active commercial insurance, Medicare, and other liable third-party coverage at the point of adjudication, surfacing coverage that traditional monthly or quarterly eligibility files miss entirely.

This point-of-claim approach improves coordination of benefits, supports cost avoidance initiatives, and directly addresses PERM audit compliance. As Medicaid programs face HR1 improper payment standards and deadline pressure, real-time insurance discovery has become essential to compliance strategy.

About Syrtis Solutions: Syrtis Solutions provides insurance discovery, coordination of benefits, and payment integrity solutions for Medicaid agencies and Medicaid managed care organizations. Through ProTPL, Syrtis helps clients identify previously unknown commercial coverage, optimize third-party liability routing, and support PERM compliance while helping clients meet Medicaid's payer-of-last-resort requirements.

For more information, contact: Steve Konsin, Jr. 866-960-9358 [email protected] www.syrtissolutions.com

Syrtis Solutions provides a monthly update on Medicaid news to help healthcare leaders monitor the evolving policy and regulatory environment. The summary highlights developments related to program integrity, coordination of benefits, cost avoidance, and the prevention of improper payments, fraud, waste, and abuse. Below is a summary of last month’s Medicaid news. Click here to learn more.

To help Medicaid stakeholders stay informed, Syrtis Solutions distributes a monthly 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.

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.

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.