Purpose

To determine whether the Department of Health provided effective oversight of State Fiscal Agent contracts to ensure contractor compliance with contract deliverables, including timely processing of provider claims for Early Intervention services provided. The audit covered the period April 1, 2013 through December 10, 2015.

Background

In New York State, the Department of Health (Department) is the lead agency responsible for the Early Intervention Program (Program). The mission of the Program is to identify and evaluate as early as possible those infants and toddlers from birth to three years of age whose healthy development is compromised and provide for appropriate intervention to improve child and family development. Early Intervention (EI) services, such as physical therapy and speechlanguage pathology services, are provided at no cost to an eligible child’s family, and are funded first through third-party payers, including commercial insurance and Medicaid. The State and counties share the remaining costs. The Program serves more than 60,000 children annually, at a cost of about $556 million. Legislation effective April 1, 2013 required the Department to begin using a State Fiscal Agent (SFA) to administer EI claims and payments. The Department engaged an interim SFA, followed by a five-year, $42.8 million contract with the current SFA, Public Consulting Group (PCG). In total, the Department has paid $19.1 million since April 1, 2013 for SFA services.

Key Findings

• The Department generally provides effective oversight of the SFA that helps ensure EI claims are paid timely and the SFA fulfills contract deliverables related to customer service and data and reporting.
• Despite improvement in the SFA’s timeliness of EI claim payments, as of September 2015, there were 169,615 unpaid claims totaling $10.9 million that were submitted from July 1, 2013 through June 30, 2015. These claims required further actions by the SFA, insurers, or providers to resolve.
• Of the 169,615 unpaid claims, more than 18,000 claims (totaling nearly $1.4 million) had been outstanding for more than 17 months.

Key Recommendations

• Take prompt action to resolve the 169,615 unpaid claims by working with PCG, providers, and third-party payers. Continue to address any remaining barriers to timely payment of EI claims.
• Work with PCG to gather input on potential enhancements to online training and customer service to better meet stakeholder needs.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Program – Appropriateness of Medicaid Eligibility Determined by the New York State of Health System (2014-S-4)
Office for the Aging/Department of Health: Social Adult Day Services (2014-S-31)