Objective

To determine the extent of implementation of the three recommendations included in our initial audit report, Improper Fee-for-Service Payments for Services Covered by Managed Long-Term Care Plans (Report 2018-S-65).

About the Program

The State’s Medicaid program offers managed long-term care (MLTC) coverage to people who are chronically ill or disabled and who wish to stay in their homes and communities. MLTC plans offer a range of services, such as home health care, nursing home care, dentistry, vision care, and durable medical equipment. The Department of Health (Department) established contracts that identify the services that plans must cover and pay for (benefit packages) in exchange for monthly premium payments for each member enrolled. Some services are excluded (i.e., carved out) from benefit packages and may be paid separately by Medicaid fee-for-service (FFS). The Medicaid program should not pay claims on a FFS basis for MLTC plan covered services.

We issued our initial audit report on January 17, 2020. The audit objective was to determine whether the Department made improper FFS payments for certain services covered by MLTC plans. The audit covered the period from January 1, 2014 through June 30, 2019. Our audit identified $16.4 million in improper Medicaid FFS payments for MLTC covered services. Of these overpayments, $15.6 million was paid because the Department did not configure eMedNY system edits and MLTC benefit packages correctly, so eMedNY did not correctly identify certain services as the responsibility of the MLTC plan. The remaining $877,000 was improperly paid because, at the time eMedNY adjudicated the claim, the recipient was not enrolled in MLTC, but was retroactively enrolled at a later date.

Key Findings

Department officials have made some progress in addressing the problems we identified in the initial audit report; however, further actions are still needed. For instance, since the initial audit, we identified about $4.3 million in additional improper Medicaid FFS payments for MLTC covered services from July 1, 2019 through February 15, 2021. Of the initial report’s three audit recommendations, two were partially implemented and one was not 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 the follow-up report.