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 October 2022 through March 2023, and certain claims going back to June 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 March 31, 2023, eMedNY processed over 233 million claims, resulting in payments to providers of nearly $45 billion. The claims are processed and paid in weekly cycles, which averaged about 9 million claims and $1.7 billion in payments to providers.

Key Findings

The audit identified over $20.6 million in improper Medicaid payments, as follows:

• $12.2 million was paid for managed care premiums on behalf of Medicaid recipients who had other concurrent comprehensive third-party health insurance;
• $5.6 million was paid for claims that were billed with incorrect information pertaining to other health insurance coverage that recipients had, or where Medicaid was incorrectly designated as the primary payer instead of another insurer;
• $1.3 million was paid for newborn birth and maternity claims that contained inaccurate information, such as the newborn’s birth weight;
• $1.2 million was paid for pharmacy, practitioner, inpatient, managed care capitation, and clinic claims that did not comply with Medicaid policies; and
• $256,777 was paid for fee-for-service inpatient claims that should have been paid by managed care.

As a result of the audit, about $7.4 million of the improper payments was recovered. We also identified three Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs. In response to the findings, the Department removed two of the providers from the Medicaid program and the remaining provider was still under review.

Key Recommendations

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