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, 2016 through September 30, 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 September 30, 2016, eMedNY processed about 202 million claims, resulting in payments to providers of about $29 billion. The claims are processed and paid in weekly cycles, which averaged over 7.8 million claims and $1.1 billion in payments to providers.

Key Findings

The audit identified approximately $16.6 million in potential and actual Medicaid cost savings, as follows:

• $13.6 million in potential savings for Medicaid recipients diagnosed with end stage renal disease who were entitled to Medicare coverage at the time of the claims;
• $1.1 million in improper episodic payments to home health care providers;
• $845,824 in overpayments for newborn claims that were submitted with incorrect birth weights;
• $471,321 in overpayments for claims billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $357,498 in improper payments for inpatient, durable medical equipment, clinic, child care, and transportation services;
• $160,759 in overpayments for an inpatient claim that was billed at a higher level of care than what was actually provided; and
• $25,354 in improper payments for duplicate billings.

By the end of the audit fieldwork, about $1.8 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 15 providers that we identified. Prior to program termination, Medicaid paid 9 of the 15 providers a total of $99,038 from the date they were charged with a crime to their termination date. The Department should assess whether these payments should be recovered.

Key Recommendation

• We made eight 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, 2015 Through March 31, 2016 (2015-S-74)