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, 2017 through March 31, 2018.

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, 2018, eMedNY processed over 184 million claims, resulting in payments to providers of more than $31 billion. The claims are processed and paid in weekly cycles, which averaged over 7.1 million claims and $1.2 billion in payments to providers.

Key Findings

The audit identified over $119 million in Medicaid payments that require the Department’s prompt attention, as follows:

• $107.7 million in Medicaid managed care premiums were paid on behalf of recipients with concurrent comprehensive third-party health insurance (TPHI);
• $3.2 million was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $2.1 million was paid for claims involving the Medicare Savings Program;
• $1.7 million in fee-for-service claims was paid for recipients enrolled in managed care;
• $1.6 million was paid for newborn birth claims;
• $1.4 million was paid for an inpatient claim that was billed at a higher level of care than what was actually provided;
• $609,915 was paid for Comprehensive Psychiatric Emergency Program claims that were billed in excess of permitted limits; and
• $360,651 was paid for clinic and inpatient claims; $357,020 was paid for drugs purchased through the federal 340B program; and $290,676 was paid for episodic home health care claims that did not comply with Medicaid policies.

By the end of the audit fieldwork, about $6.7 million of the improper payments had been recovered.

Further, of the $107.7 million in premiums paid on behalf of Medicaid recipients with concurrent comprehensive TPHI, about $5.7 million pertained to Nassau County. During the audit, auditors assisted Nassau County officials in identifying Medicaid recipients who had comprehensive TPHI while enrolled in Medicaid managed care. Nassau County officials subsequently disenrolled 619 Medicaid recipients who were improperly enrolled in managed care, saving the Medicaid program an estimated $2.1 million in managed care premiums for the six-month period April 2018 through September 2018.

Auditors also identified 38 active Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs. By the end of the audit fieldwork, the Department terminated 21 of the providers, entered in Medicaid settlements with 14, and needed to make a decision on the program status of the remaining 3 active providers.

Key Recommendations

We made 14 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, 2016 Through March 31, 2017 (2016-S-66)
Department of Health: Medicaid Claims Processing Activity April 1, 2017 Through September 30, 2017 (2017-S-23)