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, 2012 through March 31, 2013.

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, 2013, eMedNY processed about 167 million claims resulting in payments to providers of about $26 billion. The claims are processed and paid in weekly cycles, which averaged about 6.4 million claims and $995 million in payments to providers.

Key Findings

Auditors identified about $13 million in inappropriate or questionable Medicaid payments, including:

• $6,329,458 in questionable payments for claims that were not subjected to the appropriate edits and pricing logic due to eMedNY's incorrect designation of the claim type being processed;
• $2,965,300 in overpayments for claims billed with incorrect information pertaining to recipients' other health insurance coverage;
• $2,689,352 in inappropriate payments for lab services claims submitted well beyond the required time frame for submission;
• $488,837 in overpayments for claims for duplicate billings;
• $222,806 in overpayments for claims for a dialysis drug billed at 10 times the number of units actually provided; and
• Claims with improper payments for physician-administered drugs, hospital services, medical equipment, and dental services.

By the end of the audit fieldwork, auditors recovered about $3.8 million of the overpayments identified.

Auditors also identified 26 providers in the Medicaid program who had been charged with or found guilty of crimes that violate health care programs' laws or regulations. The Department terminated 19 of these providers, but the status of the seven others was still under review.

Key Recommendations

We made 19 recommendations to the Department to recover the remaining inappropriate Medicaid payments and improve claim processing controls.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Claims Processing Activity April 1, 2012 Through September 30, 2012 (2012-S-24)
Department of Health: Controls Over eMedNY Edit Changes (2007-S-139)