Objective

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, 2018 through September 30, 2018.

About the Program

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, 2018, eMedNY processed over 154 million claims, resulting in payments to providers of more than $35 billion. The claims are processed and paid in weekly cycles, which averaged over 5.9 million claims and $1.4 billion in payments to providers.

Key Findings

The audit identified over $134 million in Medicaid payments that require the Department’s prompt attention, as follows:

• $123.9 million in Medicaid managed care premiums was paid on behalf of 86,475 Medicaid recipients who had concurrent comprehensive third-party health insurance (TPHI);
• $6.1 million was paid for an inpatient claim that contained an inaccurate deductible amount;
• $1.1 million was paid for inpatient claims that were billed at a higher level of care than what was actually provided;
• $1 million was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $977,817 was paid for newborn birth claims that contained inaccurate birth information, such as the newborn’s birth weight;
• $515,615 was paid for psychiatric claims that were billed in excess of permitted limits; and
• $504,679 was paid for practitioner, pharmacy, and clinic claims and $326,697 was paid for episodic home health care claims that did not comply with Medicaid policies.

By the end of the audit fieldwork, about $8.2 million of the improper payments had been recovered. Also, according to Department officials, as of January 31, 2019, they successfully disenrolled 9,334 individuals from Medicaid managed care due to comprehensive TPHI. 

Auditors also identified 32 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 removed 28 of the providers from the Medicaid program, entered into a settlement with 1 provider, and was determining the program status of the remaining 3 providers. 

Key Recommendations

We made 11 recommendations to the Department to recover the remaining inappropriate Medicaid payments and improve claims processing controls.