Objective

To determine whether the Department of Health’s (Department’s) 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 2021 through March 2022 and certain claims going back to June 2021.

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 March 31, 2022, eMedNY processed over 294 million claims, resulting in payments to providers of nearly $42 billion. The claims are processed and paid in weekly cycles, which averaged about 11.3 million claims and over $1.6 billion in payments to providers.

Key Findings

The audit identified over $22 million in improper Medicaid payments, as follows:

• $11.5 million was paid for managed care premiums on behalf of Medicaid recipients who also had concurrent comprehensive third-party health insurance;
• $8.9 million was paid for clinic, practitioner, inpatient, managed care, and laboratory claims that did not comply with Medicaid policies, such as billing in excess of permitted limits;
• $1 million was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer;
• $825,875 was paid for fee-for-service inpatient claims that should have been paid by managed care or that were also reimbursed by managed care; and
• $104,594 was paid for inpatient claims that were billed at a higher level of care than what was actually provided.

As a result of the audit, about $9.9 million of the improper payments had been recovered by the end of the audit fieldwork. We also identified 11 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 them from the Medicaid program.

Key Recommendations

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