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

Our initial audit report, which was issued on April 3, 2012, identified $1.9 million in Medicaid overpayments to Cabrini Medical Center. The overpayments occurred because a billing company (hired by Cabrini) incorrectly altered information on Cabrini's claims and resubmitted the incorrect claims to Medicaid. In these instances, the original claim was correct and should not have been adjusted and resubmitted. Auditors additionally referred $618,000 in potential overpayments to the Department of Health (Department) for further review. Auditors determined the eMedNY system did not have the controls necessary to identify unreasonable or suspicious adjustment claims. We made six recommendations to the Department to recover the Medicaid overpayments made to Cabrini, investigate the billing company, and implement controls within eMedNY to identify questionable adjustment claims.

Key Findings

Department officials made significant progress in addressing the problems we identified in the initial audit. This included the recovery of improper payments totaling $1,460,503 (in addition to $904,000 in payments prevented by the initial audit). However, further actions are still needed. Of the six prior audit recommendations, three were implemented and three were partially implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

Other Related Audit/Report of Interest

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