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, 2016 through March 31, 2017.

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, 2017, eMedNY processed over 192 million claims, resulting in payments to providers of more than $29 billion. The claims are processed and paid in weekly cycles, which averaged over 7.4 million claims and $1.1 billion in payments to providers.

Key Findings

The audit identified approximately $12.4 million in improper Medicaid payments, as follows:

• $4.58 million in overpayments for long-stay inpatient claims that were billed at higher levels of care than what was allowed;

• $2.9 million in overpayments for Comprehensive Psychiatric Emergency Program claims that were billed in excess of permitted limits;

• $1.4 million in overpayments for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had;

• $1.1 million in improper inpatient claims for newborns who were not enrolled into managed care in a timely manner;

• $1 million in overpayments for newborn claims that were submitted with incorrect birth weights;

• $705,466 in improper episodic payments to home health care providers;

• $404,227 in overpayments for dental anesthesia claims that were reimbursed excessive amounts due to flaws in the processing and payment of the claims; and

• $274,390 in overpayments for other inpatient, clinic, and durable medical equipment claims.

By the end of the audit fieldwork, about $6.3 million of the overpayments had been recovered.

Auditors also identified providers in the Medicaid program who were charged with or found guilty of crimes that violated health care programs’ laws or regulations. The Department terminated 22 of the providers we identified from the Medicaid program, but the status of two providers was still under review at the time our fieldwork was completed.

Key Recommendations

We made 12 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, 2015 Through March 31, 2016 (2015-S-74)
Department of Health: Medicaid Claims Processing Activity April 1, 2016 Through September 30, 2016 (2016-S-12)