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 April 1, 2012 through September 30, 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 September 30, 2012, eMedNY processed about 163 million claims resulting in payments to providers of about $25 billion. The claims are processed and paid in weekly cycles, which averaged about 6.3 million claims and $950 million in provider payments.

Key Findings

Auditors identified about $2 million in overpayments resulting from:

• Claims billed with information from other health insurance plans that was inaccurate, which caused $675,265 in overpayments;
• Claims with incorrect billings for alternate levels of care, which caused $465,313 in overpayments;
• Claims for dental services that should have been covered by a managed care plan, which caused $336,780 in overpayments; and
• Claims with improper payments for inpatient services, physician-administered drugs, duplicate procedures, transportation services, eye care services, and nursing home and other services.

At the time fieldwork was completed, auditors had recovered about $1.5 million of the overpayments that were identified. Thus, Department officials need to take actions to recover overpayments totaling about $500,000.

Key Recommendations

• We made 19 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 April 1, 2011 Through September 30, 2011 (2011-S-9)