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, 2014 through March 31, 2015.

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, 2015, eMedNY processed about 264 million claims, resulting in payments to providers of about $28.5 billion. The claims are processed and paid in weekly cycles, which averaged about 10.1 million claims and $1.1 billion in payments to providers.

Key Findings

Auditors identified about $4.3 million in inappropriate Medicaid payments. The audit found:

• $1,956,679 in overpayments for newborn claims that were submitted with incorrect birth weights;
• $1,061,204 in overpayments for inpatient claims that were either billed at a higher level of care than what was actually provided or were billed with incorrect patient status codes;
• $590,405 in overpayments for claims billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $476,888 in improper payments for pharmacy claims that were not in compliance with State Medicaid policies; and
• $167,101 for claims with improper payments for duplicate billings and for clinic and durable medical equipment services.

By the end of the audit fieldwork, about $3.7 million of the overpayments were recovered.

Auditors also identified providers in the Medicaid program who were charged with or found guilty of crimes that violate health care programs’ laws or regulations. The Department terminated 13 of the providers we identified, but the status of 16 other providers was still under review at the time our fieldwork was completed.

Key Recommendations

We made 13 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, 2014 Through September 30, 2014 (2014-S-15)
Department of Health: Medicaid Claims Processing Activity October 1, 2013 Through March 31, 2014 (2013-S-50)