Objective

To assess the extent of implementation of the three recommendations included in our initial audit report, Payments by UnitedHealthcare for Medical/Surgical Services for Ineligible Members (Report 2020-S-34).

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, local government, and school district employees, and their dependents. The Empire Plan is the primary health insurance plan for NYSHIP, covering 1.1 million members. Civil Service contracts with UnitedHealthcare Insurance Company of New York (United) to administer the Empire Plan’s medical/surgical benefits.

Civil Service is responsible for maintaining the New York Benefits Eligibility and Accounting System (NYBEAS), the system of record for member enrollment and eligibility information. Eligibility information is entered into NYBEAS by a participating employer’s health benefits administrator (HBA) as well as by Civil Service. Civil Service provides United with a daily update file of NYBEAS changes, and United also has access to NYBEAS to confirm eligibility information.

Our initial audit report, issued on September 29, 2021, sought to determine whether United paid medical/surgical claims for Empire Plan members who were not eligible for coverage. Our audit covered the period January 1, 2014 through December 31, 2019. We identified $5.7 million that was paid for medical/surgical services for ineligible members.

Key Findings

Civil Service and United have made significant progress in addressing the issues identified in the initial audit. United recovered about $500,000 of the $5.7 million in overpaid benefits we identified. Further, since the end of the initial audit period, Civil Service and United identified another $10.9 million in claims for ineligible members, of which about $4.9 million has been recovered. In addition, Civil Service and United have implemented quarterly reconciliations of eligibility information between NYBEAS and United’s system. Of the initial report’s three audit recommendations, two were implemented and one was partially implemented.

Key Recommendation

Officials are given 30 days after the issuance of this follow-up to provide information on any actions that are planned to address the unresolved issues discussed in this report.