Medicaid Program: Claims Processing Activity April 1, 2024 Through September 30, 2024
Learn how the AI-generated research projects were createdOverall Conclusion
The audit concluded that eMedNY reasonably ensured Medicaid claims were submitted by approved providers, processed in accordance with Medicaid requirements, and paid correctly overall. However, improvements were needed in the processing of certain claim types, with over $11.5 million identified as improper payments during the 6-month period ended September 30, 2024; DOH recovered more than $2.6 million and was urged to continue to recover the remaining amount and strengthen controls.
Source Document
Audit Scope
The audit covered the Department of Health’s eMedNY Medicaid claims processing system and its administration of the State’s Medicaid program, focusing on whether Medicaid claims were submitted by approved providers and processed in accordance with Medicaid requirements, and whether payments to providers were correct. The scope includes the 6-month period ended September 30, 2024 (April 1, 2024 through September 30, 2024) and certain claims going back to January 2022. During the period, eMedNY processed almost 249 million claims with payments totaling nearly $50.6 billion, in weekly cycles averaging about 9.6 million claims and $1.9 billion in payments. The audit examined both fee-for-service and managed care claim processing, the disenrollment and premium payment processes, and various policy areas such as primary payer designation, supplemental capitation payments for newborns and maternity, and the handling of provider sanctions. The audit employed non-statistical sampling (2,010 judgmental claims totaling about $170 million; 78 random pharmacy claims totaling about $2.9 million; and all claims related to comprehensive third-party coverage) and relied on data from the Medicaid Data Warehouse and eMedNY, among other sources.
Key Findings Summary
Improper Managed Care Premium Payments for Members With Comprehensive Third-Party Health Insurance: The disenrollment process led to improper Medicaid premium payments totaling $8,335,321 during April 2024 through September 2024, including $2,077,415 for members enrolled through NYSOH and $6,257,906 for non-NYSOH enrollees.
Improper Fee-for-Service Payments for Inpatient Services Covered by Managed Care: 90 overpayments totaling $1,609,501 occurred where fee-for-service payments were made for members who had managed care coverage; 84 overpayments (including 75 newborns) were due to retroactive managed care coverage, with 70 claims adjusted for $1,255,443; 20 claims totaling $35…
Incorrect Maternity and Newborn Birth Claims Involving Managed Care (including Supplemental Low Birth Weight Newborn Capitation Payments and Supplemental Maternity Capitation Payments): 22 claims with erroneous birth information or diagnosis codes resulted in overpayments totaling $1,341,969, all adjusted by fieldwork end; Supplemental Low Birth Weight Newbo…
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AI-Assisted
AI Scope Summary
Assess the Department of Health’s eMedNY Medicaid claims processing controls to ensure claims are submitted by approved providers, processed per Medicaid rules, and paid correctly, for the 6-month period April 1–September 30, 2024 (with certain claims back to January 2022), and evaluate actions taken to recover improper payments and sanction noncompliant providers.
AI-Generated Insight
The Medicaid claims processing audit highlights the importance of robust, end-to-end controls across enrollment, eligibility, and claims adjudication systems. While the eMedNY platform largely functions as intended, targeted weaknesses in disenrollment timing, retroactive coverage, and data reporting for newborn and maternity claims generated substantial improper payments. The findings underscore the value of timely cross-system reconciliations, proactive monitoring of third-party payer interactions, and ongoing collaboration between DOH, OMIG, NYSOH, and investigative authorities to safeguard program integrity and maximize recoveries.
Audit Objectives
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, for the period April 1, 2024 through September 30, 2024, and certain claims going back to January 2022.
Audit Findings (6)
Improper Managed Care Premium Payments for Members With Comprehensive Third-Party Health Insurance: The disenrollment process led to improper Medicaid premium payments totaling $8,335,321 during April 2024 through September 2024, including $2,077,415 for members enrolled through NYSOH and $6,257,906 for non-NYSOH enrollees.
Improper Fee-for-Service Payments for Inpatient Services Covered by Managed Care: 90 overpayments totaling $1,609,501 occurred where fee-for-service payments were made for members who had managed care coverage; 84 overpayments (including 75 newborns) were due to retroactive managed care coverage, with 70 claims adjusted for $1,255,443; 20 claims totaling $354,058 still require adjustment.
Incorrect Maternity and Newborn Birth Claims Involving Managed Care (including Supplemental Low Birth Weight Newborn Capitation Payments and Supplemental Maternity Capitation Payments): 22 claims with erroneous birth information or diagnosis codes resulted in overpayments totaling $1,341,969, all adjusted by fieldwork end; Supplemental Low Birth Weight Newborn Capitation payments totaled $1,198,800 for 10 claims (overpayments corrected); Supplemental Maternity Capitation Payments totaled $143,169 across 12 claims (overpayments corrected).
Improper Payments for Inpatient, Referred Ambulatory, and Clinic Claims: $222,220 in overpayments across 1 inpatient, 9 referred ambulatory, and 6 clinic claims due to billing errors, including a per diem misbilling for a hospital stay, incomplete records for four claims, practitioner-administered drugs billed above cost, and duplicate claims; some adjustments were made totaling $1,426 in savings, but $220,794 remains unresolved as of fieldwork end.
Other Insurance on Medicaid Claims: Overpayments totaling $50,283 across seven claims where Medicaid was incorrectly designated as the primary payer; $30,648 recovered from four adjusted claims, $19,635 across three claims still needing adjustment; $3,623 in overpayments from excessive copayments, with $1,700 recovered and $1,923 awaiting adjustment; providers were reminded to bill other insurers first.
Status of Providers Who Violate Program Requirements: The audit identified 14 Medicaid providers charged with or convicted of crimes; 13 were removed from the Medicaid program and one was referred to the New York State Attorney General.
Recommendations (7)
Review the $8.3 million in overpayments, disenroll the members from managed care plans, and make recoveries, as appropriate.
Review the $354,058 in overpayments and make recoveries, as appropriate.
Formally advise the MCOs and hospitals identified in this audit to accurately report newborn claim information when billing Medicaid to ensure appropriate payment.
Review the $220,794 in overpayments and make recoveries, as appropriate.
Remind the providers of their obligation to bill all applicable third parties that may be liable for a claim before billing Medicaid.
Review the $21,558 in overpayments and make recoveries, as appropriate.
Ensure providers who violate Medicaid or other health insurance program provisions are subject to appropriate and timely sanctions, including removal from the Medicaid program.