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, 2015 through September 30, 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 September 30, 2015, eMedNY processed about 192 million claims, resulting in payments to providers of about $28.4 billion. The claims are processed and paid in weekly cycles, which averaged about 7 million claims and over $1 billion in payments to providers.

Key Findings

Auditors identified about $12.1 million in inappropriate Medicaid payments. The audit found: 

• $7,134,184 in overpayments for Managed Long Term Care (MLTC) capitation payments made for recipients who were retroactively disenrolled from an MLTC plan;
• $2,282,626 in overpayments for deceased Medicaid recipients enrolled through New York State of Health, the Department’s online marketplace for health insurance;
• $1,052,058 in overpayments for claims billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $813,412 in overpayments for newborn claims that were submitted with incorrect birth weights;
• $708,016 in overpayments for inpatient claims that were billed at a higher level of care than what was actually provided; and
• $77,861 in improper payments for duplicate billings and claims for clinic, transportation, durable medical equipment, and eye care services.

By the end of the audit fieldwork, about $2.1 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 26 of the providers we identified, but the status of five other providers was still under review at the time our fieldwork was completed. 

Key Recommendation

• We made 11 recommendations to the Department to recover the remaining inappropriate Medicaid payments and improve claims processing controls.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Claims Processing Activity October 1, 2014 Through March 31, 2015 (2014-S-53)
Department of Health: Medicaid Claims Processing Activity April 1, 2014 Through September 30, 2014 (2014-S-15)