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, 2015 through March 31, 2016.

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, 2016, eMedNY processed about 200 million claims, resulting in payments to providers of about $29 billion. The claims are processed and paid in weekly cycles, which averaged over 7.7 million claims and $1 billion in payments to providers.

Key Findings

The audit identified approximately $6.8 million in inappropriate Medicaid payments, as follows:

• $3,521,562 in overpayments for fee-for-service claims for recipients whose services were covered by managed care;
• $1,342,307 in overpayments for claims billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $937,424 in overpayments for newborn claims that were submitted with incorrect birth weights;
• $389,813 in improper payments for inpatient, clinic, durable medical equipment, transportation, and eye care services;
• $333,504 in improper payments identified by the Centers for Medicare & Medicaid Services that the Department did not recover from providers;
• $260,330 in overpayments for inpatient claims that were billed at a higher level of care than what was actually provided; and
• $50,767 in improper payments for duplicate billings.

By the end of the audit fieldwork, about $2.4 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 14 of the providers we identified, but the status of one provider was still under review at the time our fieldwork was completed.

Key Recommendations

We made nine 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 April 1, 2015 Through September 30, 2015 (2015-S-16)
Department of Health: Medicaid Claims Processing Activity October 1, 2014 Through March 31, 2015 (2014-S-53)