Objective

To assess the extent of implementation of the six recommendations included in our initial audit report, Improper Payments for Services Related to Ordering, Prescribing, Referring, or Attending Providers No Longer Participating in the Medicaid Program (Report 2019-S-72).

About the Program

The Department of Health (Department) administers New York’s Medicaid program. The Affordable Care Act and implementing federal regulations mandated that State Medicaid agencies require all ordering and referring physicians and other professionals providing services through the Medicaid fee-for-service program to be enrolled as participating providers in the State Medicaid program. Accordingly, beginning January 1, 2014, New York’s Medicaid program required that physicians and other health care professionals who order, prescribe, refer, or attend (OPRA) Medicaid services be appropriately screened and enrolled in Medicaid and have an "active" provider status. Through the screening and provider enrollment process, the Department gains a level of assurance over the OPRA provider’s validity to provide Medicaid services. It also allows the Department to verify the provider’s licensing and other credentials to furnish services. Additionally, the Department must verify that no providers are prohibited from participating in a Medicaid program by the federal government, which further enhances the safety of the Medicaid program and its members.

The objective of our initial audit report, issued April 19, 2022, was to determine whether the Department made improper payments for claims in violation of federal and State requirements related to OPRA providers who were no longer participating in the Medicaid program. The audit found that the Department’s eMedNY claims processing system edits designed to prevent payments of Medicaid claims for services with an inactive OPRA provider were flawed and failed to check the provider’s active status. We determined Medicaid made $965 million in payments for 2.3 million OPRA services by physicians and professionals who were no longer actively enrolled in Medicaid on the service date.

Key Findings

Department officials made limited progress in addressing the problems we identified in the initial audit report and additional actions are still needed. For example, less than 1% of the $965 million had been recovered and, we note, the Office of the Medicaid Inspector General (OMIG) was unable to demonstrate that any of the recoveries were related to our audit’s objective. In addition, the Department had not enhanced eMedNY system controls to more timely identify OPRA providers who were not actively enrolled in Medicaid and deny the related claims. Of the initial report’s six audit recommendations, one was implemented and five were not implemented.

Key Recommendation

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