Objective
To determine whether the Department of Health (DOH) provided adequate oversight to ensure managed care recipients in the Recipient Restriction Program received services from the appropriate providers. The audit covered the period from July 2018 through May 2023.
About the Program
DOH administers the New York State Medicaid program. Under federal authorization, the Recipient Restriction Program (Restriction Program) was created to reduce the cost of inappropriate utilization by identifying Medicaid recipients who demonstrate a pattern of misusing and abusing the Medicaid program. Medicaid recipients in the Restriction Program must receive certain care through only their designated health care providers or via referral from those providers. Generally, claims for non-emergency services submitted for a restricted recipient should not be paid if the service is not provided or referred by the designated providers. The Office of the Medicaid Inspector General (OMIG) is responsible for administering and monitoring the Restriction Program. Managed care organizations (MCOs) are contractually required to continue OMIG’s efforts by administering recipient restrictions, identifying recipients who should be placed in the program, and ensuring restricted services are provided or referred by the designated providers.
Key Findings
- A lack of oversight by DOH and OMIG led to MCOs paying approximately $117 million for clinic, inpatient, practitioner, laboratory, and durable medical equipment services on behalf of Medicaid recipients who had designated Restriction Program providers on file in eMedNY, yet received services that were not furnished or referred by the designated providers.
- MCOs did not consistently implement Restriction Program requirements and did not have effective mechanisms in place to ensure recipients received restricted services from designated providers or that designated providers made referrals as required.
- One MCO had its Restriction Program claims processing controls turned off for over 3 years and paid $23.4 million (of the $117 million) for 96,397 claims between March 2020 and May 2023 without enforcing recipient restrictions.
- Another MCO did not implement any claims processing controls to enforce the Restriction Program. During the audit period, this MCO paid 37,336 claims totaling $4.6 million without enforcing recipient restrictions.
Key Recommendations
- Review the identified $117 million in payments on behalf of restricted recipients and determine whether any recoveries should be made or any penalties assessed.
- Take steps to ensure MCOs consistently and appropriately enforce Restriction Program policies and regulations, including monitoring claims and determining whether any recoveries should be made or any penalties assessed.
Andrea Inman
State Government Accountability Contact Information:
Audit Director: Andrea Inman
Phone: (518) 474-3271; Email: [email protected]
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236