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WATCH: Medicaid Program Looks to Negotiate Rising Drug Prices

Federal data reveals Medicaid spending on prescription drugs rose 25% in 2014 and an additional 14% in 2015, marking a sharp increase. At present, Medicaid is required to cover any FDA-approved drugs, including drugs with similar purposes. Massachusetts is looking to bring the price back down by picking and choosing which drugs they are required…

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Federal data reveals Medicaid spending on prescription drugs rose 25% in 2014 and an additional 14% in 2015, marking a sharp increase. At present, Medicaid is required to cover any FDA-approved drugs, including drugs with similar purposes. Massachusetts is looking to bring the price back down by picking and choosing which drugs they are required to offer. They argue the new rule will give them missing leverage that will save money for Medicaid and patients alike. Critics argue it makes accessing drugs more difficult for low-income patients who may not have options for inexpensive alternatives. The proposal is currently being reviewed by the Centers for Medicare and Medicaid Services, which has an unpredictable record on approvals.

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Denials get a queue, underpayments just look like paid claims

Denials get a queue, underpayments just look like paid claims

Underpayments in healthcare revenue cycle operations lack the visibility of denied claims because they don't trigger alerts or queue workflows. Without dedicated ownership and line-level verification against contract terms, paid claims that fall short of their contractual amount pass through undetected.

  • 01Denial workflows activate on rejection events, but underpayments produce no event, leaving paid claims unverified by default.
  • 02The speaker says many provider groups lack line-level contract intelligence to check each paid line against the applicable terms.
  • 03Payment received and payment checked are separate tasks: one verifies acceptance, the other verifies correctness—and the second often has no assigned owner.

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A zero-paid claim line is not automatically an underpayment

A zero-paid claim line is not automatically an underpayment

A zero payment on a claim line isn't automatically an underpayment; contract terms, particularly packaging rules, determine whether zero is correct. Chasing unsupported findings damages credibility with payers and weakens the position of legitimate disputes, so revenue cycle teams must verify the full contract terms and effective dates before treating any payment difference as a finding.

  • 01When a contract packages add-ons into the primary procedure, the add-on line may legitimately show zero payment because it is folded into the primary procedure reimbursement.
  • 02Pursuing payment differences that lack contract support burns credibility with payers and can weaken the team’s position on later disputes, including valid ones.
  • 03Always verify the complete contract terms, fee schedules, carve-outs, amendments, and the specific version in effect on the date of service before treating a payment variance as a recoverable underpayment.

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A clean, paid, closed claim can still be short of the contract

A clean, paid, closed claim can still be short of the contract

Practices can receive payment on closed, clean claims that still fall short of negotiated contract amounts because billing ends at coding, submission and posting, while no role owns checking whether payer payments match fee schedules. The speaker argues that contract-level payment review is a separate, complementary function that compares closed claims to contract terms and, run continuously, helps surface shortfalls in time to act within timely filing windows.

  • 01Correctly coded and billed healthcare claims can still result in underpayment.
  • 02Practices should review closed-claim payments against contract terms to spot underpayments.
  • 03Discrepancies in claim payments can persist despite adherence to billing protocols.

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