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 April 2021 through September 2021, and certain claims going back to March 2016.

About the Program

The Department administers the State’s Medicaid program. The Department’s eMedNY computer system processes 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 September 30, 2021, eMedNY processed over 121 million claims, resulting in payments to providers of more than $38 billion. The claims are processed and paid in weekly cycles, which averaged about 4.7 million claims and almost $1.5 billion in payments to providers.

Key Findings

The audit identified over $36.1 million in improper Medicaid payments, as follows:

• $28.5 million was paid for managed care premiums on behalf of enrollees who also had concurrent comprehensive third-party health insurance;
• $3.7 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;
• $1.4 million was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer;
• $847,926 was paid for fee-for-service inpatient claims on behalf of recipients with multiple client identification numbers;
• $714,336 was paid for inpatient claims that were billed at a higher level of care than what was actually provided;
• $482,074 was paid for practitioner, clinic, inpatient, episodic home health care, and psychiatric claims that did not comply with Medicaid policies, such as billing in excess of permitted limits;
• $354,475 was paid for newborn birth claims that contained inaccurate birth information, such as the newborn’s birth weight; and
• $132,108 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 $5.5 million of the improper payments had been recovered.

Auditors also identified seven providers in the Medicaid program 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 the providers from the Medicaid program.

Key Recommendations

We made 18 recommendations to the Department to recover the remaining inappropriate Medicaid payments and improve claims processing controls.