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MAY 2025 MEDICAID POLICY & NEWS SUMMARY

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.

Click this link to read the news.

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STATES CONFRONT MEDICAID COSTS WITH POLICY AND TECHNOLOGY

Across the United States, Medicaid has become a significant financial concern for state governments. What was once a safety net program is now consuming nearly a third of state budgets, forcing lawmakers to reckon with rising costs and inefficiencies. Medicaid expansion, prolonged enrollment protections, and pandemic-driven increases have pushed participation to historic highs, and with it, the cost to maintain the program has ballooned.

Now, facing mounting deficits and a shifting policy environment, states are acting decisively to get Medicaid spending under control.

IMPROPER PAYMENTS FUEL THE SPENDING SURGE

A significant source of Medicaid’s financial pressure lies in its high rate of improper payments. In fiscal year 2023 alone, the Centers for Medicare & Medicaid Services (CMS) reported over $50 billion in payments that shouldn't have happened, most tied to missing or unverifiable eligibility documentation.

Cumulatively, improper Medicaid payments have cost taxpayers over $543 billion in the past decade. These aren’t just accounting errors—they reflect deep operational flaws that make the program vulnerable to waste, abuse, and fraud.

POLICYMAKERS LAUNCH INTEGRITY INITIATIVES

In response, several states are deploying tough new policies to restore program integrity and weed out inefficiencies:

Indiana has ended self-attestation for Medicaid eligibility and now mandates ongoing cross-checks against federal and state databases. The state has also implemented quarterly reporting on fraud prevention and payment accuracy.

Texas has upgraded its eligibility verification systems to include IRS and third-party data checks, automating what were previously manual processes.

Florida and Missouri are conducting more frequent eligibility redeterminations and increasing scrutiny of Medicaid Managed Care Organizations (MCOs).

Arkansas and Georgia are utilizing data-driven redetermination strategies to streamline enrollment and prevent ongoing eligibility lapses.

States are no longer waiting for federal intervention. They’re proactively tightening controls to reduce errors, cut unnecessary costs, and better target assistance.

MODERN TECH: THE MISSING PIECE IN MEDICAID REFORM

While legislative reforms are a step in the right direction, they won’t succeed without modern infrastructure to support them. Technology is key to implementing oversight at scale, in real time.

That’s why more Medicaid plans are turning to platforms like ProTPL from Syrtis Solutions.

ProTPL is a real-time, automated system that identifies third-party liability (TPL) before Medicaid pays a claim—ensuring Medicaid acts as the payer of last resort. It enables state plans to:

Block improper payments before they happen, rather than recovering them later,

Automatically detect commercial coverage on pharmacy and medical claims,

Reduce manual eligibility checks to improve efficiency and accuracy.

Comply with federal cost avoidance and COB mandates with minimal effort.

ProTPL enables Medicaid plans to respond more quickly, operate more efficiently, and prevent losses at the source.

THE PATH FORWARD: STRONG POLICY + SMART TECHNOLOGY

As the fiscal burden of Medicaid grows heavier, one thing is clear: status quo systems won’t cut it. States that combine aggressive policy reform with smart, proven technology will be best positioned to rein in spending, reduce fraud, and protect coverage for the people who need it most.

Click here to learn more.

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MEDICAID DEVELOPMENTS AND INSIGHTS - APRIL 2025

Stay up to date with Syrtis Solutions' monthly Medicaid news roundup! Each edition delivers the latest updates on Medicaid program integrity, cost avoidance, coordination of benefits, and efforts to combat fraud, waste, and abuse. We cover key policy changes, legislative developments, and research insights shaping the Medicaid landscape. Here’s a recap of last month’s most important Medicaid news.

Learn more here.

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March 2025 Medicaid News Roundup

Stay informed 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 combat fraud, waste, and abuse. Our roundup highlights key policy changes, research insights, and legislative developments impacting the Medicaid landscape. Here’s a look at last month’s most important Medicaid news.

Read here.

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MEDICAID AND MCOS FACE TIGHTER MARGINS AMID $880 BILLION IN PROPOSED BUDGET CUTS

As of March 18, Medicaid Managed Care Organizations (MCOs) are preparing for potentially transformative changes as federal lawmakers propose reducing Medicaid funding by $880 billion over the next ten years. The sweeping proposal could lead to scaled-back eligibility, loss of coverage for millions, and mounting financial stress for state programs and the MCOs that manage them.

In response, MCOs are beginning to examine operational models, cost-control measures, and digital solutions to safeguard care delivery in an increasingly resource-constrained environment.

Federal Budget Proposal Could Reshape Medicaid Structure

The budget resolution introduced by the U.S. House of Representatives outlines substantial cuts aimed at curbing federal spending. For Medicaid, the proposed changes would not only reduce federal contributions but also shift more financial responsibility to states. In practical terms, MCOs could face shrinking per-member funding, increased scrutiny of reimbursements, and higher expectations around administrative efficiency.

Waste Reduction Emerges as a Key Strategy

Improper payments—including fraud, waste, and billing errors—remain a costly vulnerability within Medicaid. Each year, billions are lost to inaccuracies that strain already-limited funds. In light of the proposed cuts, MCOs are being urged to tighten internal controls and invest in technologies that support more accurate claims processing and fraud detection.

Predictive analytics, AI-driven audits, and automated eligibility verification systems are among the tools gaining traction to help reduce overpayments and reinforce fiscal discipline.

States Respond with Financial Band-Aids and Long-Term Planning

Several states have already begun to adjust their approach to Medicaid financing and operations in anticipation of federal retrenchment:

California has allocated $3.4 billion from its general fund to cover shortfalls in Medi-Cal, its Medicaid program, citing a surge in enrollment and expanding coverage policies as key cost drivers.

Kentucky lawmakers are exploring efficiency-based reforms, aiming to reduce system waste without cutting core services. Legislative conversations have centered around optimizing care coordination and improving oversight.

Iowa is advancing a fraud-first strategy, emphasizing enforcement and tighter controls as a way to limit unnecessary spending and preserve coverage for those most in need.

Technology Plays a Growing Role in Medicaid Modernization

Faced with mounting pressures, many MCOs are turning to private-sector innovation. Companies like Syrtis Solutions have introduced tools that assist in reducing duplicate claims, catching ineligible reimbursements, and lowering administrative costs. These solutions offer MCOs the opportunity to streamline operations, improve data integrity, and increase accountability—critical advantages as federal funding becomes less predictable.

The Outlook: Navigating a Leaner, Smarter Medicaid Ecosystem

As the possibility of large-scale cuts grows more likely, Medicaid Managed Care Organizations must act with urgency. Reducing payment errors, strengthening compliance, and integrating modern technology into everyday operations will be essential to sustain care quality and operational viability.

Though the next decade may bring fiscal tightening, it also presents a moment for reinvention. MCOs that act decisively now—focusing on integrity, adaptability, and innovation—will be better equipped to lead Medicaid into a more sustainable and efficient future.

Click here to continue reading.

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STATE STRATEGIES FOR SUSTAINING MEDICAID AMID BUDGET CUTS

With federal budget cuts placing Medicaid funding under increasing pressure, states are working to ensure that millions of vulnerable residents continue to receive essential healthcare. Rising costs, growing enrollment, and financial uncertainties have led policymakers to develop strategies for maintaining Medicaid sustainability. Here’s how various states are addressing these fiscal hurdles.

California’s Strategy to Close Budget Gaps

California is grappling with a $3.4 billion Medicaid deficit, forcing the state to rely on its general fund to support Medi-Cal. The financial shortfall is driven by an increase in beneficiaries and expanded coverage. State leaders are considering adjustments in cost structures, seeking alternative funding sources, and evaluating policy reforms to maintain program stability.

Kentucky’s Measures to Streamline Spending

Kentucky officials are analyzing Medicaid expenditures to identify areas where efficiency can be improved without reducing coverage. Lawmakers are discussing initiatives to minimize administrative waste, enhance cost-sharing approaches, and optimize provider reimbursements to sustain access to healthcare services.

Louisiana’s Medicaid Resources

Local officials are raising concerns about impending federal funding cuts that could severely impact critical services like Medicaid and crisis intervention centers. These cuts pose a significant risk to healthcare access for vulnerable populations, potentially leading to service reductions, longer wait times, and increased pressure on already strained local resources. Leaders are actively exploring solutions to counter these financial challenges and ensure continued support for communities reliant on these essential programs.

Iowa’s Focus on Fraud Prevention

Iowa legislators, including Representative Ashley Hinson, are prioritizing fraud reduction as a method to cut unnecessary Medicaid spending. By enhancing fraud detection systems and implementing stricter regulations, the state aims to ensure funds are allocated efficiently while protecting beneficiaries from coverage losses.

West Virginia’s Push Against Proposed Cuts

In West Virginia, healthcare advocates are actively opposing Medicaid reductions, citing the potential harm to vulnerable populations. Policymakers and advocacy groups are working together to prevent service disruptions and maintain funding to support those in need, particularly in rural areas.

The Future of Medicaid in an Uncertain Fiscal Landscape

With federal budget cuts on the horizon and financial strains mounting, states and Medicaid programs must take proactive measures to protect their funding and sustain vital healthcare services. To ensure Medicaid’s financial health, states and managed care organizations (MCOs) should focus on eliminating improper payments, enhancing fraud prevention, and improving operational efficiency. By optimizing resource allocation and accountability, Medicaid can continue delivering essential care to vulnerable populations while maintaining fiscal stability in an increasingly uncertain economic environment.

Click here to read more.

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FEBRUARY 2025 MEDICAID NEWS ROUNDUP

Stay informed 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 combat fraud, waste, and abuse. Our roundup highlights key policy changes, research insights, and legislative developments impacting the Medicaid landscape. Here’s a look at last month’s most important Medicaid news.

Open the news.

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ACT NOW: PREVENT MEDICAID CUTS BY ELIMINATING IMPROPER PAYMENTS

With billions in Medicaid funding at risk under the latest House budget proposal, state programs are facing serious financial threats. To sustain critical healthcare services, Medicaid agencies and Managed Care Organizations (MCOs) must take immediate action to safeguard every dollar. A key step in this effort is addressing the ongoing issue of improper payments—an issue that drains over $80 billion from Medicaid annually.

The Hidden Crisis: Medicaid’s Inefficient Payment System

For nearly two decades, Medicaid’s improper payment problem has kept it on the Government Accountability Office’s (GAO) high-risk list. While fraud garners much attention, the real culprits behind these financial losses are outdated data systems and inadequate coordination of benefits (COB).

Medicaid is legally required to be the payer of last resort, meaning other insurance coverage should be billed first. However, systemic inefficiencies prevent this from happening effectively:

Undisclosed Third-Party Liability (TPL): Over 13% of Medicaid beneficiaries have unreported private insurance, leading to avoidable Medicaid payments.

Disorganized and Outdated Data: Eligibility records are scattered across multiple systems, making it difficult to verify primary insurance coverage before processing claims.

The Flawed “Pay and Chase” Model: Medicaid agencies attempt to recover improper payments after the fact, but they recoup only a fraction of the money lost.

With looming budget reductions, these inefficiencies are no longer just an administrative issue—they are a direct threat to Medicaid’s long-term sustainability.

The Solution: Cost Avoidance with Smarter Data

Instead of continuing to lose money on improper claims and struggling with post-payment recovery, Medicaid programs must adopt a cost avoidance strategy—ensuring primary insurers are billed before Medicaid pays a claim. Achieving this requires real-time access to accurate eligibility data to verify other health insurance (OHI) coverage upfront.

Syrtis Solutions delivers a game-changing solution with ProTPL, a proprietary technology that leverages ePrescribing data—the most precise and up-to-date source of commercial insurance coverage—to:

✅ Identify up to 40% more TPL cases than existing processes. ✅ Provide real-time OHI data at the point of claim submission, preventing improper payments before they happen. ✅ Eliminate the need for costly and ineffective “pay and chase” efforts.

Why Immediate Action is Critical

Medicaid funding is at risk, and failure to act now will lead to deep cuts that could impact essential healthcare services. Every dollar lost to an improper payment is a dollar that could have been spent on patient care.

Cost avoidance isn’t just an efficiency measure—it’s an urgent necessity in the face of financial uncertainty. Syrtis Solutions provides the most effective and immediate solution for reducing waste and securing Medicaid’s future.

Take Control—Protect Medicaid Today

Don’t wait for budget cuts to dictate change. Be proactive. Strengthen Medicaid’s financial foundation now.

Contact us at info@syrtissolutions.com to learn how ProTPL can help your organization save millions and ensure Medicaid dollars are used where they’re needed most.

Find out more.

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PREPARING FOR MEDICAID BUDGET CUTS: STRATEGIES FOR STATES

Introduction

With ongoing discussions in Congress about federal budget reductions, Medicaid remains at risk for funding cuts. If these cuts occur, states will need to find ways to compensate for the shortfall, potentially leading to decreased benefits, stricter eligibility requirements, and financial strain on healthcare providers. Given Medicaid’s role in supporting low-income individuals, families, and people with disabilities, significant reductions could greatly impact healthcare access and the overall system.

To navigate these challenges, states must take proactive steps to evaluate spending, explore alternative funding sources, and advocate for policy measures that protect vulnerable communities.

Potential Medicaid Cuts and Their Consequences

As a major component of federal expenditures, Medicaid is often targeted for budget reductions. Proposed changes typically include replacing the current federal matching system with block grants, capping federal contributions, or lowering federal matching rates, which would shift more financial responsibility to states. Additionally, stricter eligibility requirements, such as work mandates, could make it harder for certain individuals to qualify.

If these cuts take effect, states will be forced to either increase Medicaid spending from their own budgets or implement reductions in services, eligibility, and provider reimbursements. Given the financial constraints many states already face, these adjustments may come with significant consequences.

Effects on Healthcare Access and State Budgets

Reduced Medicaid funding would likely limit healthcare access for millions of Americans, especially those already struggling financially. Fewer people may qualify, and those who remain eligible could see a decrease in covered services. Populations relying on long-term care, mental health services, and preventive healthcare would be particularly vulnerable.

Healthcare providers that serve a large number of Medicaid patients would also feel the impact. Many hospitals and clinics already struggle with low Medicaid reimbursement rates, and further cuts could force them to scale back services, reduce patient intake, or even shut down—especially in rural and underserved areas.

The financial strain wouldn’t stop at healthcare. State governments might be forced to make difficult budgetary choices, such as cutting funding for education and infrastructure to offset Medicaid shortfalls. Some states may explore tax increases or additional fees, which could introduce new economic challenges.

How States Can Prepare

Given the uncertainty surrounding Medicaid funding, states should take proactive measures to safeguard their healthcare systems and budgets. Key strategies include:

Evaluate and Optimize Medicaid Spending

Conduct a thorough review of expenditures to identify inefficiencies.

Strengthen fraud prevention efforts and minimize improper payments.

Streamline administrative costs to maximize available resources.

Identify Alternative Funding Sources

Explore new revenue streams, such as provider taxes or health-related fees.

Expand public-private partnerships to sustain Medicaid funding.

Implement cost-saving models like value-based payments and telehealth expansion.

Invest in Preventive Care

Expand preventive healthcare initiatives to reduce long-term costs.

Support community-based health programs to improve access and efficiency.

Advocate for Policy Flexibility

Engage in federal advocacy to prevent extreme Medicaid cuts.

Push for greater state flexibility in Medicaid administration.

Defend Medicaid expansion programs to ensure continued coverage.

Strengthen Safety Nets for Affected Individuals

Expand community health centers and hospital charity care programs.

Develop state-run subsidy initiatives for those losing Medicaid eligibility.

Partner with nonprofits to maintain healthcare access for vulnerable populations.

Conclusion

Potential Medicaid budget cuts could pose serious challenges for states, healthcare providers, and millions of low-income individuals who depend on the program. While states have limited control over federal funding decisions, they can take decisive action to minimize disruption. By optimizing spending, adopting technology solutions, securing alternative funding, advocating for flexibility, and reinforcing safety nets, states can better prepare for possible reductions. Strategic planning now can make the difference between a healthcare crisis and a manageable transition. States must remain vigilant in protecting access to essential healthcare services for their most vulnerable populations.

Read more.

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MEDICAID NEWS IN JANUARY

Syrtis Solutions sends out a monthly Medicaid news roundup to help you stay up-to-date. The monthly recap focuses on developments, analysis, and legislation that pertains to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of last month's significant Medicaid developments.

Learn more here.

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MEDICAID 2024 - A LOOK BACK

Syrtis Solutions delivers an annual Medicaid news summary to help you stay informed. The monthly roundup highlights developments, analysis, and legislation that relates to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of last month's significant Medicaid developments.

Click this link and read the news.

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MEDICAID NEWS IN DECEMBER

Syrtis Solutions delivers a monthly Medicaid news recap to help you stay informed. The monthly recap concentrates on developments, research, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a list of last month's important Medicaid news.

See the news.

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NOVEMBER MEDICAID NEWS ROUNDUP

Syrtis Solutions publishes a monthly Medicaid news summary to help you stay up-to-date. The monthly roundup highlights developments, analysis, and legislation that pertains to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's significant Medicaid developments.

Open the news.

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GAO REPORT: ADDRESSING IMPROPER PAYMENTS IN MEDICAID

Improper payments and fraud continue to be chronic and costly hurdles for Medicaid and other government-funded programs. The GAO defines improper payments as payments that should not have been made or that were made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. According to the GAO, the federal government loses between $233 billion and $521 billion annually to fraud alone.

Since FY 2003, executive branch agencies have reported increasing improper payment estimates totaling approximately $2.7 trillion. In fiscal year 2023 alone, federal agencies reported $236 billion in improper payments across 71 programs. While the 2023 estimate represents an $11 billion decrease from the prior year, this reduction is associated with temporary flexibilities granted during the COVID-19 public health emergency. These measures, such as relaxed eligibility requirements for Medicaid beneficiaries and providers, reduced instances of improper payments under the adjusted criteria.

Medicaid's High-Risk Status

Medicaid has been on the GAO's High-Risk List since 2003 due to vulnerabilities in payment integrity. In FY 2023 alone, HHS estimated that Medicaid improper payments totaled $50 billion. According to HHS, the leading factors for these payments are missing or insufficient documentation, particularly in validating beneficiary eligibility and payments to ineligible beneficiaries or ineligible services.

Actions and Legislative Initiatives to Reduce Improper Payments:

CMS has made some progress in identifying these vulnerabilities. For instance, CMS collaborated with states and audit contractors to bolster oversight of healthcare companies contracted to manage healthcare services for Medicaid beneficiaries. Investigations rose from 16 between 2016 and 2018 to 893 between 2019 and 2021, uncovering significant overpayments.

Over time, several legislative efforts have been aimed at curbing fraud, waste, and abuse. Despite these bills, Medicaid continues to lose billions of dollars because of payments made in error. The measures directed by the legislation are costly and primarily revolve around compliance and reporting instead of reducing improper payments.

Remaining Challenges:

The GAO identified several areas for improvement, including:

Provider Screening and Enrollment Requirements

The GAO suggested that CMS review state compliance with screening and enrollment requirements and monitor noncompliance on a yearly basis. While CMS has provided technical assistance, further action is needed to assess and address all states' compliance.

Medical Reviews for Improper Payments

The GAO advised CMS to strengthen Medicaid's medical review processes to identify the root causes of improper payments and carry out corrective actions. As of March 2024, HHS disagreed with this recommendation and does not plan to implement it.

Compliance with Payment Integrity Information Act of 2019

In FY 2023, Medicaid was deemed compliant with PIIA criteria. However, Medicaid was not fully compliant in fiscal years 2021 and 2022.

Substantial gaps remain in addressing improper payments and fraud. Federal agencies and programs like Medicaid can better safeguard taxpayer dollars, reduce waste, and improve operational efficiency by fully implementing GAO recommendations and enhancing oversight. Nevertheless, to stop improper payment rates from rising even more, agencies should look to innovate data solutions to identify and prevent fraud, waste, and abuse.

Continue learning here.

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OCTOBER MEDICAID NEWS

Syrtis Solutions distributes a monthly Medicaid news roundup to help you stay informed. The monthly roundup focuses on developments, research, and legislation that pertains to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's significant Medicaid developments.

Learn more here.

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SYRTIS SOLUTIONS ACHIEVES ACAP PREFERRED VENDOR DESIGNATION

Syrtis Solutions, a leading service provider of real-time Other Health Insurance (OHI) coverage information for payers of last resort, just recently accomplished a notable milestone by being identified as a preferred vendor for the Association for Community Affiliated Plans (ACAP). This achievement is a reflection of Syrtis Solutions' commitment to decreasing costs and improving operational efficiency for government-funded health plans.

The Significance of Cost Avoidance in Medicaid

The Medicaid landscape is complicated and continually evolving, with state and federal guidelines mandating strict cost-control measures to ensure the program's sustainability. One of the fundamental methods for managing costs in Medicaid programs is avoiding improper claims payments, which entails identifying third-party liability (TPL) and ensuring that Medicaid is the payer of last resort.

Without effective cost avoidance mechanisms, Medicaid programs can suffer from unnecessary expenditures, driving up costs and diverting resources away from other vital healthcare needs. This is where Syrtis Solutions has been making a significant impact.

Syrtis Solutions: Leaders in Real-Time Cost Avoidance

Founded in 2008, Syrtis Solutions has been at the leading edge of developing innovative solutions to deal with the challenges of OHI identification and cost avoidance. Their flagship product, ProTPL, is a real-time pharmacy cost avoidance solution that provides Medicaid and other government-funded health plans with immediate access to actionable data. By quickly identifying whether a member has other insurance coverage, ProTPL helps plans avoid paying for claims that should be covered by liable commercial plans. This not only helps Medicaid plans comply with federal regulations but also dramatically reduces the time and effort required to manually identify third-party insurers and recover costs retroactively.

The ACAP Preferred Vendor Designation: What It Means

ACAP is a national trade association that represents 78 nonprofit Safety Net Health Plans, covering more than 25 million individuals through Medicaid, Medicare, and other public health programs. ACAP's Preferred Vendor program is designed to highlight companies that offer valuable services to member health plans and have a proven track record of improving the quality and efficiency of care.

By becoming an ACAP Preferred Vendor, Syrtis Solutions has joined an elite group of companies that have exhibited a strong commitment to serving community health plans. This designation demonstrates Syrtis Solutions' expertise and reliability in the Medicaid space, as well as its dedication to helping ACAP member plans improve cost avoidance efforts.

Looking Ahead

As healthcare costs continue to increase and Medicaid plans face increasing pressure to control expenditures, the role of payment integrity will only grow in value. With its newly cemented status as an ACAP Preferred Vendor, Syrtis Solutions is well-positioned to help all payers of last resort get through these challenges, making certain that limited healthcare dollars are used efficiently and effectively.

Syrtis Solutions' innovative real-time cost avoidance technology, combined with its proven expertise, offers an essential resource for Medicaid plans seeking to enhance their operational efficiency and reduce unnecessary spending. This partnership marks a significant step forward in improving Medicaid cost management and patient care across the nation.

Click here to learn more.

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MEDICAID NEWS IN SEPTEMBER

Syrtis Solutions issues a monthly Medicaid news summary to help you stay informed. The monthly roundup concentrates on developments, research, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's important Medicaid news.

Click here and read the news.