Objective

To determine whether UnitedHealthcare Insurance Company of New York paid claims for Empire Plan members who were not eligible. The audit covered the period from January 1, 2014 through December 31, 2019.

About the Program

The New York State Health Insurance Program (NYSHIP) provides health insurance coverage to over 1.2 million active and retired State, local government, and school district employees, and their dependents. The Empire Plan is the primary health insurance plan for NYSHIP, serving about 1.1 million members. The Department of Civil Service (Civil Service) contracts with UnitedHealthcare Insurance Company of New York (United) to administer the medical/surgical portion of this plan. From January 1, 2014 through December 31, 2019, United processed and paid over $16.6 billion in medical/surgical claims.

Civil Service maintains eligibility and enrollment records for NYSHIP members in the New York Benefits Eligibility and Accounting System (NYBEAS). Civil Service sends United daily files of NYBEAS eligibility changes and United has access to NYBEAS to confirm eligibility information. Up-to-date enrollment records are necessary to process payments accurately and prevent financial losses. For instance, contracts that United negotiates with health care providers may include limitations on the recovery of claims paid for members who were retroactively disenrolled (when a member is disenrolled from NYBEAS after the date eligibility ended). For contracts that do not include this language, typically improperly paid claims may be recovered for six years.

Key Findings

We identified $5.7 million that United paid for members who were not eligible for Empire Plan coverage. The improper payments occurred because the member was retroactively disenrolled ($4.6 million), or the claims were paid for services that occurred either before a member was enrolled or after United was notified the member was disenrolled ($1.1 million).

Key Recommendations

• Review the $5.7 million in claims paid for ineligible members and make recoveries, as warranted.
• Take steps to ensure all recoverable claims are identified and pursued for recovery to the fullest extent practicable.
• Take steps to ensure eligibility information in NYBEAS and United’s eligibility system is complete, accurate, and up to date, including, but not limited to, a periodic reconciliation process.