Purpose

To determine whether officials of United HealthCare implemented the recommendation contained in our audit report, entitled New York State Health Insurance Program: Upcoding of Selected Evaluation and Management Services (Report 2006-S-11) and a follow-up to this audit (Report 2007-F-41).

Background

The New York State Health Insurance Program (Program) provides health insurance coverage to active and retired State, participating local government and school district employees and their dependents. The Empire Plan is the primary health benefits plan for the Program. The New York State Department of Civil Service (Department) contracts with United HealthCare (United) to process and pay medical claims for services provided to Empire Plan members.

In our initial audit, we estimated United overpaid between $4,999,636 and $6,487,932 to providers who billed at a higher paying CPT code for an E/M service than the service actually performed. This practice is commonly referred to as upcoding.

Key Finding

Since the last time we followed up on the issue, United completed a major project to review claim payments for E/M services and identify upcoded claims.  As a result, United recovered over $1 million in overpayments.

Recommendation

None

Other Related Audits/Reports of Interest

United HealthCare: New York State Health Insurance Program - Upcoding of Selected Evaluation and Management Services (2006-S-11)
United HealthCare: New York State Health Insurance Program - Upcoding of Selected Evaluation and Management Services (Follow-Up) (2007-F-41)