Purpose

To determine whether Mark Amir, a physical therapist participating in New York’s Medicaid program, billed Medicaid in accordance with its policies and guidelines and whether Medicaid made improper payments. The audit covers the period April 1, 2010 through September 30, 2013.

Background

Mark Amir is a physical therapist who owns and operates Madison Physical Therapy located in Brooklyn, New York. Mr. Amir’s patients are primarily “dual-eligible” beneficiaries who are enrolled in both Medicare and Medicaid. Under this arrangement, Medicare is the primary payer and Medicaid pays beneficiaries’ Medicare deductibles and coinsurance. Medicaid claims for Medicare deductibles or coinsurance are called “crossover” claims. In December 2009, the Department of Health (Department) implemented an automated crossover process whereby Medicare sends crossover claim data electronically to eMedNY, the Department’s Medicaid claims processing system. The crossover system improved the accuracy of Medicaid payments for dualeligible recipients. Prior to the implementation, providers reported Medicare payment information on separate claims to Medicaid. This often resulted in significant Medicaid overpayments when providers misreported pertinent Medicare claim payment data. Nevertheless, providers can still report Medicare payment information directly to Medicaid instead of using the crossover system. During our audit period, Medicaid paid Mark Amir $305,215.

Key Findings

• Medicaid overpaid Mark Amir $146,225 because he reported incorrect Medicare payment information to Medicaid. He avoided Medicaid’s automated claims processing controls by submitting Medicare claims using the National Provider Identifier (NPI) for his group practice and the related Medicaid claims using his NPI as an individual provider.
• Mark Amir did not comply with certain Department regulations and administrative procedures for Medicaid program participation. As such, the propriety of the remaining Medicaid payments (totaling $158,990) to Mr. Amir is questionable.

Key Recommendations

• Recover Medicaid overpayments totaling $146,225 for Mark Amir’s improper crossover claims.
• Review the remaining claim payments totaling $158,990 and determine if recoveries and/or sanctions are warranted.

Other Related Audits/Reports of Interest

Department of Health: Overpayments of Certain Medicare Crossover Claims (2011-S-28)
Department of Health: Overpayments of Claims for Selected Professional Services (2010-S-73)
Department of Health: Overpayments for Services Also Covered by Medicare Part B (2010-S-50)