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, 2020 through September 30, 2020 and certain claims going back to April 7, 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 providers for their claims. During the six-month period ended September 30, 2020, eMedNY processed over 151 million claims, resulting in payments to providers of more than $38 billion. The claims are processed and paid in weekly cycles, which averaged about 5.6 million claims and $1.4 billion in payments to providers.

Key Findings

The audit identified over $9.7 million in improper Medicaid payments that require the Department’s prompt attention, as follows:

• $4.5 million was paid for an incorrect retroactive rate adjustment;
• $2.1 million was paid for inpatient claims that were billed at a higher level of care than what was actually provided;
• $892,790 was paid for services rendered prior to, but billed during, the Coronavirus Disease state of emergency that would have been denied had certain eMedNY edits not been relaxed in response to the crisis;
• $844,172 was paid for clinic, practitioner, pharmacy, inpatient, managed care capitation, and episodic home health care claims that did not comply with Medicaid policies;
• $738,903 was paid for newborn birth claims that contained inaccurate birth information, such as the newborn’s birth weight and diagnosis code;
• $486,951 was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had; and
• $199,943 was paid for psychiatric claims that were billed in excess of permitted limits.

By the end of the audit fieldwork, about $6.8 million of the improper payments had been recovered.

Auditors also identified 13 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 three of the providers from the Medicaid program, and the remaining ten providers entered into federal settlements.

Key Recommendations

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