Purpose

To determine whether Accordis Inc. submitted appropriate Medicaid claims on behalf of the New York City Health and Hospitals Corporation (HHC). 

Background

Healthcare providers submit Medicaid claims to the Department of Health’s eMedNY claims processing system for payment of their services. For various reasons, eMedNY denies payment of many claims. Claims that are denied can be modified and resubmitted to eMedNY for payment. Medicaid allows healthcare billing companies, commonly referred to as service bureaus, to submit claims on behalf of healthcare providers. Service bureaus are required to enroll with Medicaid and comply with all applicable regulations and policies. New York State regulations required healthcare providers to review their claims before service bureaus submit them to eMedNY for payment.

In March 2005, HHC hired Accordis to provide billing services for HHC-affiliated providers. Accordis’ primary responsibility was to review and resubmit outpatient claims that were originally submitted by HHC providers and denied by eMedNY. To accomplish this, Accordis determined the reason(s) for claim denials, reviewed pertinent patient medical files and claim information, and resubmitted the corrected claims to eMedNY for payment. For the three-year period ended December 31, 2010, Accordis submitted 192,296 claims totaling more than $26.2 million on behalf of HHC providers.

Key Findings

• eMedNY does not provide a mechanism for associating a paid claim to its previously denied claim. As a result, we could not determine whether changes made by Accordis to previously denied claims were appropriate.
• We identified 6 claims totaling $533 that were not properly supported by medical documentation.
• HHC providers do not review claims submitted by Accordis prior to submission of the claims to eMedNY, as required by New York State regulations.

Key Recommendations

• Implement eMedNY enhancements that provide a mechanism for linking paid claims with previously denied claims.
• Formally remind HHC to review the propriety of claims prior to Accordis (or any other service bureau) submitting them to eMedNY, as required by New York State regulations.
• Review the $533 in payments we identified and recover inappropriate payments. 

Other Related Audit/Report of Interest

Department of Health: Overpayments to Cabrini Medical Center (2011-S-8)