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 October 1, 2011 through March 31, 2012.

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 March 31, 2012, eMedNY processed approximately 233 million claims resulting in payments to providers of about $25 billion. The claims are processed and paid in weekly cycles which averaged about 9 million claims and $974 million in payments to providers.

Key Findings

• Auditors identified about $4.1 million in overpayments resulting from:
  • Incorrect retroactive rate changes that caused overpayments totaling $2.4 million;
  • Claims billed with information from other health insurance plans that was inaccurate, which caused $530,710 in overpayments;
  • Inpatient claims billed with high (intensive) levels of care that should have been based on less costly "alternate" levels of care, which caused overpayments of $412,737;
  • Claims for childcare services while the recipient was hospitalized, which caused overpayments of $256,510; and
  • Claims with improper payments for physician-administered drugs, inpatient services, duplicate procedures, medical equipment, transportation services and nursing home services.

• At the time the audit's fieldwork was completed, the auditors recovered about $3.8 million of the overpayments identified.
• Auditors also found 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 17 of the providers we identified, but the status of another 19 providers was still under review.

Key Recommendations

We made 17 recommendations to the Department to recover the inappropriate Medicaid payments and to improve claims processing controls.

Other Related Audit/Report of Interest

Department of Health: Medicaid Claims Processing Activity October 1, 2010 Through March 31, 2011 (2010-S-65)