Objective

To determine the extent of implementation of the two recommendations included in our initial audit report, Overpayments for Out-of-Network Anesthesia Services Provided at In-Network Ambulatory Surgery Centers (Report 2017-S-35).

About the Program

The New York State Health Insurance Program (NYSHIP) covers over 1.2 million active and retired State, local government and school district employees, and their dependents. NYSHIP’s primary health benefit plan is the Empire Plan. UnitedHealthcare (United) administers the medical/surgical portion of the Empire Plan (medical/surgical benefits cover services such as physician office visits, diagnostic testing, and outpatient surgical procedures). Ambulatory Surgery Centers (ASCs) are health care facilities focused on providing same-day surgical care. To help control costs, certain in-network ASCs have contract provisions that require all anesthesia services provided to Empire Plan members at their facilities to be performed by in-network anesthesia providers.

Our initial audit report, issued on August 13, 2018, examined whether United overpaid for out-of-network anesthesia services provided at ASCs that were contractually required to use in-network anesthesia providers. For the period January 1, 2012 through December 31, 2016, we identified $991,357 in overpayments that occurred because United paid for out-of-network anesthesia services provided at ASCs that were contractually required to use in-network anesthesia providers.

Key Finding

United officials made significant progress in addressing the problems we identified in the initial audit, including recovering $780,478 of the $991,357 in identified overpayments. Of the initial report’s two audit recommendations, one was implemented and one was partially implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.