Purpose

To determine the extent of implementation of the two recommendations included in our initial audit report, Improper Payments to a Physical Therapist (Report 2013-S-15).

Background

The State’s Medicaid program provides a wide range of health care services, including physical therapy services, to individuals who are economically disadvantaged and/or have special health care needs. Many of the State’s Medicaid recipients are also enrolled in Medicare, the federal health insurance program for the elderly and disabled. Individuals enrolled in both programs are commonly referred to as “dual-eligible.” Medicare is generally the primary payer for medical services provided to dual-eligible people. As the secondary payer, Medicaid generally pays balances, including deductibles and coinsurance, not paid by Medicare.

We issued our initial audit report on December 15, 2014. The audit objectives were to determine whether Mark Amir, a physical therapist who owned and operated Madison Physical Therapy located in Brooklyn, New York, billed Medicaid in accordance with its policies and whether Medicaid made improper payments. The audit covered the period April 1, 2010 through September 30, 2013. During that period, Medicaid paid Mr. Amir $305,215. Our initial audit found that Medicaid overpaid Mr. Amir $146,225 for 3,837 claims that were submitted to the Medicaid program with incorrect Medicare payment information. In addition, our audit questioned the propriety of 5,634 claims totaling $158,990 because Mr. Amir submitted claims using his National Provider Identifier for services that were rendered by other clinicians working for Madison Physical Therapy.

In our initial audit report, we made two recommendations to the Department of Health to review and recover the improper Medicaid payments we identified and to determine if sanctions were warranted.

Key Finding

Officials made some progress implementing the recommendations we made in the initial audit report. Those efforts included certain steps to recover $116,298 in overpayments made to Mr. Amir. However, at the time we completed our follow-up fieldwork, none of the overpayments were actually recovered, and additional actions were still needed. Of the initial report’s two audit recommendations, one was partially implemented and one was not implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

Other Related Audit/Report of Interest

Department of Health: Improper Payments to a Physical Therapist (2013-S-15)