Purpose

To determine the extent of implementation of the four recommendations included in our initial audit report, Overpayments of Claims for Selected Professional Services (Report 2010-S-73).

Background

Our initial audit report, which was issued on April 20, 2012, examined whether inappropriate Medicaid payments were made for selected providers who also received payments from Medicare. For the two year audit period ended December 31, 2011, we determined that, although the Department implemented the new automated crossover system in December 2009 to reduce Medicaid overpayments, it was flawed. As a result, we identified potential and actual overpayments of $100,387 for 12,715 duplicate claims that were billed for selected professional services such as podiatry, physical therapy, and occupational therapy during the calendar years 2010 and 2011. In each case, both the provider and the provider's affiliated medical group received Medicaid payments for the same service. One party billed Medicare and received a payment through the crossover system, and the other billed Medicaid directly and received a second payment. We determined the Department needs to fix a gap in eMedNY that allows certain crossover claims to be paid twice. EMedNY automated controls or "edits" are used to detect duplicate claims when one claim is billed as part of the automated crossover system and a second claim is submitted directly to Medicaid for payment. However, the edits did not prevent the duplicate claim payments we identified because each duplicate claim contained a different provider identification number. We recommended the Department correct the flaw in the eMedNY system which allowed these duplicate claims to be paid. We also recommended the Department review the potential overpayments we identified and recover overpayments where appropriate. Furthermore, we recommended the Department review additional claims for a podiatrist which we found were unsupported, and to remind providers that they must maintain medical records for services they provide.

Key Finding

Department and Office of the Medicaid Inspector General officials have made progress in correcting the problems we identified in the initial report.  However, improvements are still needed. Of the four prior audit recommendations, three were implemented and one was partially implemented.

Key Recommendation

Department officials are given 30 days after the issuance of the follow-up review to provide information on actions planned to address the unresolved issue discussed in this report.

Other Related Audit/Report of Interest

Department of Health: Overpayments of Claims for Selected Professional Services (2010-S-73)