Objective

To determine whether the Department of Health’s (Department) 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, 2019 through September 30, 2019, and select claims going back to October 1, 2015.

About the Program

The 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, 2019, eMedNY processed over 244 million claims, resulting in payments to providers of more than $35 billion. The claims are processed and paid in weekly cycles, which averaged about 9.4 million claims and $1.4 billion in payments to providers.

Key Findings

The audit identified over $8.2 million in Medicaid payments that require the Department’s prompt attention, as follows:

• $3.2 million was paid for clinic, practitioner, managed care capitation, pharmacy, inpatient, durable medical equipment, and dental claims that did not comply with Medicaid policies;
• $2.9 million was paid for maternity and newborn birth claims that contained inaccurate information, such as the diagnosis code or newborn’s birth weight;
• $1.1 million was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had;
• $767,471 was paid for inpatient claims that were billed at a higher level of care than what was actually provided;
• $225,862 was paid for episodic home health care claims that did not comply with Medicaid policies; and
• $57,597 was paid for psychiatric claims that were billed in excess of permitted limits.

By the end of the audit fieldwork, about $4.2 million of the improper payments had been recovered.

Auditors also identified 21 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 18 of the providers from the Medicaid program, entered into settlements with 2 providers, and was determining the program status of the remaining provider.

Key Recommendations

We made 12 recommendations to the Department to recover the remaining inappropriate
Medicaid payments and improve claims processing controls.