Purpose

To determine whether Medicaid made improper payments to providers who submitted Part B cost-sharing claims directly to eMedNY. The audit covered the period from June 1, 2012 through May 31, 2017.

Background

Many of the State’s Medicaid recipients are also eligible for Medicare, the federal health insurance program for people age 65 or older and people under 65 with certain disabilities. Individuals enrolled in both programs are commonly referred to as “dual-eligible.” The Medicare program has multiple parts. Medicare Part B provides supplementary medical insurance coverage for a range of outpatient medical services, physician services, and medical supplies. Medicare enrollees are responsible for paying all costs of Part B services until their annual deductible is met. After the deductible is met, Medicare begins to pay its share and the enrollee is responsible for any coinsurance. Typically, Medicare will pay 80 percent of its approved amount for a service and the enrollee is responsible for the remaining 20 percent. Generally, Medicaid will pay these Part B cost-sharing amounts (e.g., deductibles and coinsurance) on behalf of dual-eligibles.

In December 2009, the Department of Health (Department) implemented its automated Medicare/Medicaid crossover system. Under this system, providers submit medical claims for dual-eligibles to Medicare. After Medicare processes the claims, they are automatically transferred to the Department’s eMedNY system for payment of deductibles and coinsurance. The intent of the automated crossover system was to minimize the need for providers to self-report Medicare claim data to eMedNY and thereby improve the accuracy of Medicaid payments for dual-eligibles. In certain instances, providers may still submit these claims directly to eMedNY for payment (i.e., self-report Medicare data). In these situations, the claims bypass the payment controls enforced by the crossover system.

Key Findings

Auditors identified up to $8.7 million in improper payments for costs related to Medicare Part B deductibles and coinsurance between June 1, 2012 and May 31, 2017. Specifically, the audit found that Medicaid made:

• Questionable payments totaling $5.3 million to providers who claimed excessive Part B coinsurance amounts.
• Overpayments totaling $2.3 million to providers for the Part B coinsurance on services Medicaid did not cover.
• Overpayments totaling $1.1 million to providers for Part B deductibles that exceeded dual-eligibles’ yearly limits.

Key Recommendations

• Review the payments identified by the audit and recover overpayments, as appropriate.
• Formally advise providers to report accurate claim information when billing Medicaid for Part B deductibles and coinsurance on direct-bill claims to help ensure claims are paid appropriately.
• Enhance system controls to detect and prevent overpayments for Part B deductibles and coinsurance on direct-bill claims.

Other Related Audits/Reports of Interest

Department of Health: Reducing Medicaid Costs for Recipients With End Stage Renal Disease (2015-S-14)
Department of Health: Medicaid Claims Processing Activity April 1, 2017 Through September 30, 2017 (2017-S-23)