Purpose

To determine whether the Department of Health's eMedNY system reasonably ensured that Medicaid claims were submitted by approved providers, were processed in accordance with Medicaid requirements, and resulted in correct payments to the providers. The audit covered the period April 1, 2011 through September 30, 2011.

Background

The Department of Health (Department) administers the State's Medicaid program. The Department's eMedNY computer system processes Medicaid claims submitted by providers for services rendered to Medicaid eligible recipients, and it generates payments to reimburse the providers for their claims. During the six-month period ended September 30, 2011, eMedNY processed approximately 178 million claims resulting in payments to providers of about $25 billion. The claims are processed and paid in weekly cycles which averaged about 6.8 million claims and $954 million in payments to providers.

Key Findings

• Auditors identified about $7.8 million in overpayments resulting from:
  • Claims billed with information from other health insurance plans that was inaccurate. About $6.4 million in overpayments were attributable to claims which had excessive amounts for coinsurance, copayments, or deductibles from other plans;
  • Duplicate claims for the same procedures;
  • Inpatient claims billed with incorrect patient status codes and with high (intensive) levels of care that should have been based on less costly "alternate" levels of care;
  • Claims for a recipient who did not live in New York State; and
  • Improper claims for certain clinic services, physician-administered drugs, and vision care.
• Auditors recouped about $7.5 million of these overpayments and took steps to prevent future overpayments.
• Auditors also found 21 providers in the Medicaid program who were charged with or found guilty of crimes that violate Medicaid program laws or regulations. The Department promptly terminated 20 of these providers, but the status of the remaining provider (whom Medicaid paid $5,164 after his sentencing) was still under review.

Key Recommendations

We made 20 recommendations to the Department to recover the inappropriate Medicaid payments and to improve claim processing controls.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Claims Processing Activity October 1, 2010 through March 31, 2011 (2010-S-65)
Department of Health: Medicaid Claims Processing Activity April 1, 2010 through September 30, 2010 (2010-S-15)
Department of Health: Medicaid Claims Processing Activity October 1, 2009 through March 31, 2010 (2009-S-71)