COST AVOIDANCE TECHNOLOGY SOLUTIONS FOR MEDICAID

Apart from climbing health care costs and increased spending from the program's expansion, Medicaid is losing billions of dollars a year from improper payments. Safeguarding the integrity of the Medicaid program has become a major priority for the Centers for Medicare and Medicaid Services (CMS). The agency and individual states are turning to technology for cost avoidance solutions to protect the program from fraud, waste, and abuse.

CMS: TRANSFORMED MEDICAID STATISTICAL INFORMATION SYSTEM 

Earlier this year, CMS and the US Comptroller General met with the Senate Homeland Security and Governmental Affairs Committee to go over the agencies initiatives to curb fraud, waste, and abuse. Administrator Verma testified and presented a number of solutions geared toward audits, but in addition, she emphasized the significance of data optimization.

According to CMS, enhancing data will "drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP."

Administrator Verma went on to present the Transformed Medicaid Statistical Information System (T-MSIS). The system partners with states to incorporate advanced analytics and technologies in the collection of health services data. T-MSIS tracks submitted key information such as beneficiary eligibility, beneficiary and provider enrollment, service utilization, claims and managed care data, and expenditure data. This information will make it possible for Medicaid programs to operate more efficiently and reduce costs.

Presently, states access federal databases for data matching and the identification of improper payments. However, the data is not current, available, complete, or accurate. While T-MSIS is still being developed and is years away from completion, Medicaid plans will continue to lose billions of dollars.

RHODE ISLAND AND TEXAS ADOPT THE MEDICAL ASSISTANCE INTERCEPT SYSTEM

Rhode Island and Texas have turned to technology to strengthen and improve their Medicaid programs. Both states have enrolled in the Medical Assistance Intercept System (MAIS).

States submit Medicaid beneficiary records into the MAIS database and they are then matched daily with personal injury and workers' compensation insurance claims. The system identifies and provides plans with matches and outreach services. States can then issue a lien to the insurer using the information from these matches. MAIS can also file with the insurers on the state's behalf. At the time of settlement, Medical claims are collected by the state.

In 2013, Rhode Island began using the MAIS to intercept payments for reimbursement to it's Medicaid program. All insurance companies who conduct business in the state of Rhode Island were mandated to enter into the program.

According to the state, "The MAIS program and Rhode Island's Executive Office of Health and Human Services (EOHHS) hit a new total of $25 Million in liens in April 2019. Achieving an exceptional increase of 25% since lien amounts were last reported [in September], MAIS has exceeded expectations and continues to grow in both scale and scope with a record single lien of $2.6 million."

In April, Texas became the second state to enroll in the program. It is using MAIS as a cost control initiative and plans to offset medical assistance expenses in the state.

ProTPL BY SYRTIS SOLUTIONS 

Outside of government-sponsored programs, there are a number of recovery services; however, none of them effectively reduce improper payments. More than a decade ago, Syrtis Solutions realized the need for cost avoidance in the Medicaid program and created ProTPL, a real-time, prospective TPL solution for payers of last resort.

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