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 from October 2020 through March 2021 and certain claims going back to October 2014.

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 6-month period ended March 31, 2021, eMedNY processed over 313 million claims, resulting in payments to providers of more than $36 billion. The claims are processed and paid in weekly cycles, which averaged about 12.1 million claims and $1.4 billion in payments to providers.

Key Findings

The audit identified nearly $7.4 million in improper Medicaid payments, as follows:

• $3.3 million was paid for fee-for-service inpatient claims that should have been paid by managed care, or that were also reimbursed by managed care;
• $1.5 million was paid for inpatient claims that were billed at a higher level of care than what was actually provided;
• $1.1 million was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had, or where Medicaid was incorrectly designated as the primary payer instead of another insurer;
• $1 million was paid for practitioner, clinic, inpatient, durable medical equipment, episodic home health care, and psychiatric claims that did not comply with Medicaid policies, such as billing in excess of permitted limits;
• $357,066 was paid for newborn birth claims that contained inaccurate birth information, such as the newborn’s birth weight; and
• $46,193 was paid for services rendered prior to, but billed during, the coronavirus disease 2019 state of emergency that would have been denied had certain eMedNY edits not been relaxed in response to the crisis.

By the end of the audit fieldwork, about $5.6 million of the improper payments had been recovered.

Auditors also identified 34 providers in the Medicaid program who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs. We advised Department officials of the providers and the Department removed eight of them from the Medicaid program.

Key Recommendations

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