Objective

To assess the extent of implementation of the two recommendations included in our initial audit report, Out-of-Network Providers Upcoding Selected Evaluation and Management Services (Report 2017-S-34).

About the Program

The New York State Health Insurance Program (NYSHIP), administered by the Department of Civil Service (Civil Service), covers active and retired State, participating local government and school district employees, and their dependents. The Empire Plan is the primary health benefits plan for NYSHIP. Civil Service contracted with UnitedHealthcare (United) to administer the medical/surgical portion of the Empire Plan.

Evaluation and Management (E/M) billing codes are divided into broad categories, such as office visits, hospital visits, and consultations. Within each category, there are different billing levels (e.g., level 1, 5-minute visit and level 5, 40-minute visit). The higher the level billed, the greater United’s reimbursement. Billing for a higher level of care than the service actually provided is known as upcoding.

Our initial audit report, issued on December 31, 2018, examined whether United sufficiently monitored out-of-network providers who routinely billed for higher-level E/M services, and if out-of-network providers billed United for higher-paying E/M services than what were actually performed. For the period January 1, 2016 through December 31, 2016, we determined 42 claims (47 percent of the 90 claims sampled) totaling $28,731 were upcoded or unsupported for the higher level of care billed. We found United’s method for monitoring out-of-network providers who billed for higher-level E/M services needed improvements.

Key Finding

United officials made progress in addressing the problems we identified in the initial audit. In particular, United saved the Empire Plan $862,334 through reviews of claims from three of nine providers identified in the initial audit. Of the initial report’s two audit recommendations, both were 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 any unresolved issues discussed in this report.