Objective

To determine whether the Department of Health’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 providers. The audit covered the period April 2022 through September 2022, and certain claims going back to January 2022.

About the Program

The Department of Health (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 generates payments to reimburse the providers for their claims. During the 6-month period ended September 30, 2022, eMedNY processed over 224 million claims, resulting in payments to providers of nearly $38 billion. The claims are processed and paid in weekly cycles, which averaged about 8.6 million claims and nearly $1.5 billion in payments to providers.

Key Findings

The audit identified over $16.7 million in improper Medicaid payments, as follows:

• $10.2 million was paid for managed care premiums on behalf of Medicaid recipients who also had concurrent comprehensive third-party health insurance;
• $2.5 million was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer;
• $2.1 million was paid for fee-for-service inpatient claims that should have been paid by managed care;
• $784,905 was paid for inpatient claims that were billed at a higher level of care than what was actually provided;
• $652,210 was paid for practitioner, clinic, inpatient, and pharmacy claims that did not comply with Medicaid policies; and
• $555,731 was paid for maternity and newborn birth claims that contained inaccurate information, such as the diagnosis code or newborn’s birth weight.

As a result of the audit, about $4.3 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, by the end of the audit fieldwork, the Department had removed three of the providers from the Medicaid program and referred two to the New York State Office of the Attorney General’s Medicaid Fraud Control Unit; the remaining six providers were under the Office of the Medicaid Inspector General’s review.

Key Recommendations

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