Purpose

To determine if BlueCross BlueShield’s (Empire’s) payments to St. Francis Hospital of Poughkeepsie (St. Francis) for special items were made according to the provisions of the agreement between Empire and St. Francis. 

Background

The New York State Health Insurance Program (NYSHIP) provides health insurance coverage to active and retired State, participating local government and school district employees and their dependents.  The Empire Plan (Plan) is the primary health benefits plan for NYSHIP.  The Department of Civil Service contracts with Empire to administer the hospitalization portion of the Plan.  Empire processes Plan claims for hospital services in accordance with agreements they negotiate with member hospitals, including St. Francis.  Empire’s payments to St. Francis are generally based on standard fee schedules.  However, St. Francis is entitled to additional payments for certain special items (such as implants, drugs, and blood) that are not covered by the standard fee schedules.  Per Empire’s agreement with St. Francis, the amounts of claims for special items should be related to St. Francis’ costs to acquire them.

Key Finding

We reviewed one claim payment to St. Francis for special items and determined Empire paid St. Francis appropriately according to the terms of Empire’s agreement with St. Francis.

Key Recommendation

None

Other Related Audits/Reports of Interest

New York State Health Insurance Program: Payments Made to Stony Brook University Medical Center (2009-S-27)
New York State Health Insurance Program/Department of Civil Service: Empire BlueCross BlueShield - Payments for Selected Items to Selected Hospitals (2010-S-74)