Purpose

To determine the implementation status of the eight recommendations made in our initial audit report, Eye Care Provider and Family Inappropriately Enroll as Recipients and Overcharge for Vision Services (Report 2013-S-1).

Background

We issued our initial audit report on March 21, 2016. The audit objectives were to determine whether the owner of a Medicaid eye care provider (Provider) and the owner’s family members and associates inappropriately enrolled as Medicaid recipients and to determine whether the Provider inappropriately billed Medicaid for vision services. The scope of the audit was from January 1, 2008 through September 30, 2013. Our audit found numerous violations and questionable practices, including:

• The owner and family members submitted false income information to obtain Medicaid benefits. The State paid $68,483 in medical benefits on behalf of the owner and the owner’s spouse and three other family members during the enrollment periods.
• We identified five additional Medicaid recipients who had a business or personal connection to a member of the Provider’s family and, we believe, submitted misleading information on their Medicaid applications to gain eligibility.
• The Provider received over $22,000 in improper Medicaid payments for claims with inappropriate coinsurance charges and for services not supported by medical records.
• The Provider allowed non-Medicaid-enrolled providers to render services, and on its claims to Medicaid identified a different, authorized, provider as the service renderer.
• The Provider used a non-Medicaid-enrolled billing service company to submit its claims. The owner of the Provider and the owner of the billing service company were married.
• The owner of the billing company used two other providers’ Medicaid identification numbers to gain unauthorized access to the eMedNY claims system and bill over $700,000 in Medicaid claims on behalf of 55 providers. In our initial audit, we made eight recommendations to the Department to: assess the eligibility of the identified Medicaid recipients, deactivate ineligible Medicaid recipients and providers, conduct an expanded review of improper Medicaid claims, recover improper State payments, and improve claims processing controls.  

In our initial audit, we made eight recommendations to the Department to: assess the eligibility of the identified Medicaid recipients, deactivate ineligible Medicaid recipients and providers, conduct an expanded review of improper Medicaid claims, recover improper State payments, and improve claims processing controls.

Key Finding

In March 2016, the Office of the Medicaid Inspector General (OMIG) commenced an investigation of the Provider, the Provider’s billing company, and the recipients identified in the original audit. At the time of our follow-up review, the investigation was ongoing and OMIG officials stated that recoveries of Medicaid overpayments and corrective actions would occur, if warranted, when the investigation was complete. Of the initial report’s eight audit recommendations, two were implemented, five were partially implemented, and one has not yet been 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: Medicaid Program - Eye Care Provider and Family Inappropriately Enroll as Recipients and Overcharge for Vision Services (2013-S-1)