Medicaid Program: Overpayments for Medicare Part C Claims
Learn how the AI-generated research projects were createdOverall Conclusion
DOH oversight identified improper Medicaid payments related to Medicare Part C cost-sharing, primarily driven by provider misinterpretation of rules, incomplete CARC reporting, and system limitations. The audit results indicate substantial recoveries and opportunities to strengthen controls, including follow-up on remaining overpayments, ongoing hospital monitoring, enhancements to eMedNY, and exploring APD data validation to improve eligibility and payment accuracy.
Source Document
Audit Scope
Audit of Medicaid payments for Medicare Part C claims for dual-eligible recipients under Medicare Advantage Plans, covering the period May 2018 through April 2023. The audit focused on hospital-based inpatient and outpatient services (excluding mental and behavioral health services) submitted to Medicaid for Part C cost-sharing liabilities, reporting adjustments via EOBs with CARCs, and the accuracy of the information reported to eMedNY. The analysis used data from DOH’s Medicaid Data Warehouse (MDW) and DOH’s eMedNY system, with a judgmental sample of 89 high-risk Part C claims drawn from five hospitals (Hospitals A–E) to assess improper payments. It did not project results to the entire population due to non-statistical sampling.
Key Findings Summary
Audited Part C claims for dual-eligible recipients from May 2018 through April 2023 identified 212,131 claims totaling about $121.4 million in high-risk categories for improper payment (coinsurance, deductible, zero-filled).
Judgmental sample of 89 claims totaling $1,325,452 found 49 overpayments totaling $881,233 (55%), with 66 of 89 claims improperly billed (74%).
Improper payments occurred due to hospital misinterpretation of state regulations and billing guidelines, hospitals not reporting CARCs, incorrect reporting of cost-sharing amounts, and limitations of the eMedNY system.
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AI-Assisted
AI Scope Summary
To build on this audit, future work could focus on ongoing monitoring of Part C claim submissions, expanding risk-based reviews to additional hospitals and plans, and evaluating the use of APD data to verify Part C cost-sharing reporting on Medicaid claims.
AI-Generated Insight
This audit highlights systemic misalignments between Medicare Part C cost-sharing rules and hospital billing practices, revealing that most improper payments were linked to deductible and zero-filled claims caused by reporting gaps and system limitations. Strengthening CARC reporting, expanding automated edits like ZEROFILL PEND CRITERIA, and leveraging the All-Payer Database for data validation could substantially reduce improper payments and improve program integrity for dual-eligible beneficiaries. The findings also underscore the value of data-sharing partnerships among DOH, OMIG, and external data sources to verify complex cost-sharing reporting across payer lines.