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 from October 2023 through March 2024, and certain claims outside this period when trends in the claims were observed that warranted follow-up.

About the Program

The Department of Health (DOH) administers the State’s Medicaid program. DOH’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, 2024, eMedNY processed over 370 million claims, resulting in payments to providers of nearly $49.6 billion. The claims are processed and paid in weekly cycles, which averaged about 14 million claims and $1.9 billion in payments to providers.

Key Findings

The audit determined eMedNY reasonably ensured Medicaid claims were submitted by approved providers, were processed in accordance with requirements, and resulted in correct payments to providers. However, we also identified the need for improvements in the processing of certain types of claims. The audit identified over $16.2 million in improper payments, as follows:

• $11.8 million was paid for managed care premiums on behalf of Medicaid recipients who should not have had managed care coverage because they had other concurrent comprehensive third-party health insurance;
• $2 million was paid for fee-for-service inpatient claims that should have been paid by managed care;
• $1.3 million was paid for newborn birth and maternity claims that contained inaccurate information, such as low newborn birth weights that increased reimbursements;
• $964,333 was paid for inpatient, pharmacy, referred ambulatory, and clinic claims that did not comply with Medicaid policies;
• $126,786 was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer; and
• $35,441 was paid for managed care premiums on behalf of incarcerated recipients whose managed care coverage should have been suspended.

As a result of the audit, more than $2.8 million of the improper payments was recovered. We also identified 10 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, DOH removed nine of the providers from the Medicaid program and had not yet resolved the program status of the remaining provider.

Key Recommendations

• We made 10 recommendations to DOH to recover the remaining inappropriate Medicaid payments and improve controls.