Objective

To determine whether the Department of Health (Department) made improper payments for claims in violation of federal and State requirements related to ordering, prescribing, referring, or attending (OPRA) providers who were no longer participating in the Medicaid program. The audit covered the period from January 2015 through December 2019.

About the Program

The New York State Medicaid program provides a wide range of medical services to those who are economically disadvantaged and/or have special health care needs. For the State fiscal year ended March 31, 2021, New York’s Medicaid program had approximately 7.3 million recipients and Medicaid claim costs totaled $68.1 billion.

The Affordable Care Act and implementing federal regulations mandated that state Medicaid agencies require all ordering and referring physicians and other professionals providing services through the Medicaid fee-for-service program to be enrolled as participating providers in the State Medicaid program. Accordingly, beginning January 1, 2014, New York’s Medicaid program required that physicians and other health care professionals who order, prescribe, refer, or attend Medicaid services be appropriately screened and enrolled in Medicaid.

Through the screening and provider enrollment process, the Department gains a level of assurance over the OPRA provider’s validity to provide Medicaid services. It also allows the Department to verify the provider’s licensing and other credentials to furnish services. Additionally, the Department must verify that no providers are prohibited from participating in a Medicaid program by the federal government, which further enhances the safety of the Medicaid program and its members.

Key Findings

We identified system processing weaknesses in eMedNY, the Department’s Medicaid claims processing system, which allowed improper payments for claims that reported a provider in a required OPRA field who was no longer actively enrolled in the Medicaid program at the time of the service (inactive provider). This resulted in $965 million in payments for claims that reported an inactive OPRA provider on the claim’s order or service date, including $5.8 million for providers who were excluded from participating in Medicaid due to past misconduct.

The Department enhanced eMedNY claim edits in February 2018 and, subsequently, we found a significant drop in the amount of improper payments. However, additional actions are still needed. For the period March 2018 through December 2019, our audit identified about $45.6 million in claim payments for 135,476 services that reported an OPRA provider who was no longer actively enrolled in Medicaid. When inactive OPRA providers are included on Medicaid claims, the Department lacks assurance that the provider can furnish such services, and it increases the risk that excluded, or otherwise unqualified, providers are providing Medicaid services.

Key Recommendations

• Review the $965 million in payments to providers for Medicaid claims that reported inactive OPRA providers and determine an appropriate course of action.
• Enhance controls to prevent improper Medicaid payments for claims that do not report an active OPRA provider.
• Update guidelines to clarify OPRA billing requirements.