Objective

To determine whether Anthem Blue Cross coordinated benefits to properly pay claims for NYSHIP Empire Plan members with Medicare coverage. The audit covered the period from January 2020 through June 2023.

About the Program

The New York State Health Insurance Program (NYSHIP), administered by the Department of Civil Service (Civil Service), is one of the nation’s largest public sector health insurance programs. NYSHIP covers about 1.2 million active and retired State, participating local government, and school district employees, and their dependents. The Empire Plan is the primary health benefits plan for NYSHIP, serving about 1.1 million of the members.

Civil Service contracts with Anthem Blue Cross (Anthem) to administer the Hospital Program of the Empire Plan. The Hospital Program includes coverage for inpatient and outpatient services provided by a hospital, skilled nursing facility, or hospice. Many enrollees and their dependents have other insurance coverage in addition to the Empire Plan such as Medicare, the federal health insurance program for people aged 65 and older and for those under age 65 with certain disabilities.

Civil Service maintains eligibility and enrollment records for NYSHIP members, which include Medicare enrollment information, and provides daily update files of changes to Anthem. The Centers for Medicare & Medicaid Services (CMS) maintains eligibility and enrollment records for Medicare-enrolled individuals and also provides monthly update files to Anthem.

Coordination of benefits is a process health insurance companies use for paying health care claims when people are covered by more than one insurance plan. This process determines which insurance plan pays first as primary and which insurance plan pays secondary. Because the insurance company which pays primary typically pays the majority of the claim, it is important to ensure that the proper coordination of benefits occurs.

Key Findings

For the audit period, we found Anthem improperly paid 241 claims totaling $5,259,416 because proper coordination of benefits did not occur. Anthem’s eligibility system was not always updated timely with members’ Medicare-related information. Additionally, weaknesses in Anthem’s and Civil Service’s reconciliation of member enrollment data prevented opportunities for recovery.

Key Recommendations

• Review the $5,259,416 in claims identified in this report as improperly paid and recover overpayments, as warranted.
• Work with Civil Service to enhance the current eligibility data reconciliation process to include reconciliation of members’ Medicare eligibility and enrollment status, including retirement dates, held harmless status, and Medicare-primacy dates.