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, 2017 through September 30, 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 September 30, 2017, eMedNY processed over 193 million claims, resulting in payments to providers of more than $31 billion. The claims are processed and paid in weekly cycles, which averaged over 7.4 million claims and $1.2 billion in payments to providers.

Key Findings

The audit identified approximately $10.2 million in improper Medicaid payments, as follows:

• $3.7 million in overpayments for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $3.1 million in overpayments for claims involving Medicare coverage that eMedNY incorrectly processed;
• $1.3 million in overpayments for improper newborn birth claims;
• $783,016 in improper fee-for-service claims for Medicaid recipients who were enrolled in a managed care plan;
• $684,457 in overpayments for Comprehensive Psychiatric Emergency Program claims that were billed in excess of permitted limits;
• $465,257 in improper episodic payments to home health care providers; and
• $172,052 in other overpayments for inpatient, clinic, practitioner, and referred ambulatory claims.

By the end of the audit fieldwork, about $4.5 million of the overpayments were 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 42 of 51 providers we identified. Prior to being terminated from the Medicaid program, eMedNY paid five of the providers a total of $292,681 from the date they were charged with a crime to their termination date. The Department should assess whether these payments should be recovered.

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 April 1, 2016 Through September 30, 2016 (2016-S-12)
Department of Health: Medicaid Claims Processing Activity October 1, 2016 Through March 31, 2017 (2016-S-66)