Objective

To determine whether UnitedHealthcare Insurance Company of New York appropriately reimbursed acupuncture and acupuncture-related services. The audit covered the period from January 1, 2015 through December 31, 2019.

About the Program

The New York State Health Insurance Program (NYSHIP), administered by the Department of Civil Service (Civil Service), provides health insurance coverage to over 1.2 million 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, serving about 1.1 million members.

Civil Service contracts with UnitedHealthcare Insurance Company of New York (United) to administer the medical/surgical portion of the Empire Plan and process and pay claims submitted by health care providers. Medical/surgical benefits cover a range of services, including acupuncture. United defines acupuncture as a technique for treating certain painful conditions by passing long thin needles through the skin to specific points. Acupuncture is sometimes provided at the same time as other services, including heat therapy, massage therapy, electrical stimulation, and evaluation and management, collectively referred to herein as acupuncture-related services.

From January 1, 2015 to December 31, 2019, United paid more than $247 million for acupuncture services and more than $48 million for acupuncture-related services that occurred during the same visit as the acupuncture service.

Key Findings

We identified $7,331,458 in actual and potential overpayments for services not supported by provider documentation and for duplicate payments during our audit period. We found:

• $210,068 in overpayments from a random sample of 836 services, from 10 providers who were paid the highest dollars, that were not supported by documentation. Based on a projection of the sample to the audit population for the 10 providers, we estimate that United made overpayments of $7,010,427.
• $223,765 in duplicate payments for services already paid on another claim, including $18,663 confirmed by United and $205,102 that still needs to be reviewed.
• $97,266 in duplicate payments for 1,619 instances where the initial 15 minutes of acupuncture services were paid twice.

United performs reviews of Empire Plan claim payments to identify providers with irregular billing patterns. Part of United’s monitoring process is flagging providers for pre-payment review when the identified irregularities are systemic. For all 10 providers sampled, eight providers were placed on prepayment review after the start of our audit, while the remaining two had been placed on pre-payment review before our audit began.

Key Recommendations

• Review the $7,331,458 in audit findings and make recoveries, as warranted.
• Enhance controls designed to prevent duplicate payments for the same service.