Evidence record
Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 2024
- Jurisdiction
- New York
- Publishing agency
- Office of the New York State Comptroller, Division of State Government Accountability
- Publication date
- February 2024
- Source record
- Original document linked
Findings
9
Recommendations
10
Overall conclusion
The audit concluded that eMedNY reasonably ensured that Medicaid claims were submitted by approved providers, processed in accordance with Medicaid requirements, and resulted in correct payments. However, the audit identified a number of improper payments across several categories, totaling over $16.2 million, with DOH needing to take further actions to recover funds and strengthen controls; 10 providers were identified as violating program requirements, with nine removed from the program during fieldwork.
Scope
The audit covered the Department of Health’s eMedNY Medicaid claims processing activity from October 1, 2023 through March 31, 2024. It included processing of claims submitted by Medicaid providers, automated edits and controls within the eMedNY system, and related governance and enforcement actions. The scope also encompassed analyses of trends observed in the claims data outside the period when such trends warranted follow-up, including Medicare/third-party payer interactions, managed care premium payments, newborn/birth-related claims, inpatient and clinic services, pharmacological claims, and provider sanctions. The audit relied on MDW and eMedNY data, with samples including 1,831 claims totaling about $158.7 million (risk-based judgmental sample), 78 pharmacy claims (~$2.6 million), and all claims not conforming to comprehensive third-party insurance rules.
Findings (9)
Each finding has a stable link.
- F-376
Improper Managed Care Premium Payments for Recipients With Comprehensive Third-Party Health Insurance (approximately $11.8 million over Oct 2023–Mar 2024) due to disenrollment processes not being timely, resulting in improper premium payments.
- F-377
Improper Fee-for-Service Payments for Inpatient Services Covered by Managed Care (88 overpayments totaling $1,969,028) due to retroactive managed care coverage and billing the fee-for-service when the recipient had managed care.
- F-378
Incorrect Newborn Birth Claims (7 claims totaling $784,741) with incorrect birth weight reporting leading to overpayments; seven claims adjusted later with $707,116 in cost savings.
- F-379
Incorrect Maternity and Newborn Birth Claims Involving Managed Care (17 claims totaling $622,446) due to reporting errors; 16 adjusted for $504,684 in savings; one remaining $117,762; July 2024 reminder issued.
- F-380
Improper Payments for Inpatient, Referred Ambulatory, and Clinic Claims ($569,435 overpayments across 4 inpatient, 30 referred ambulatory, and 2 clinic claims) with 4 adjusted ($531,322 savings) and $38,113 remaining.
- F-381
Questionable Pharmacy Claims (14 claims totaling $394,898 for Targretin 1% gel) lacking sufficient medical necessity documentation; prescriber education; no additional claims billed subsequently.
- F-382
Other Insurance on Medicaid Claims (overpayments totaling $126,786 due to incorrect designation of primary payer; $113,251 saved from one adjusted claim; $13,535 remaining).
- F-383
Improper Managed Care Premium Payments During Recipient Incarceration (25 improper premium payments totaling $35,441 for 9 incarcerated recipients) with several cases where incarcerated individuals should have been moved to fee-for-service.
- F-384
Status of Providers Who Violate Program Requirements (10 providers identified; 9 removed from Medicaid program; 1 under review).
Recommendations (10)
- R-341
Recommendation 3: Formally advise the hospitals identified to accurately report newborn claim information when billing Medicaid to ensure appropriate payment.
Related finding F-378 - R-342
Recommendation 4: Review the $117,762 in overpayments and make recoveries, as appropriate.
Related finding F-379 - R-343
Recommendation 5: Review the $38,113 ($34,350 + $3,763) in overpayments and make recoveries, as appropriate.
Related finding F-380 - R-344
Recommendation 6: Formally advise the hospital identified in this report to accurately bill Medicaid for the acquisition cost of certain practitioner-administered drugs.
- R-345
Recommendation 7: Review the $394,898 in pharmacy payments and make recoveries, as appropriate.
Related finding F-381 - R-346
Recommendation 8: Review the $13,535 in overpayments and make recoveries, as appropriate.
Related finding F-382 - R-347
Recommendation 9: Review the $35,441 in overpayments and make recoveries, as appropriate.
Related finding F-383 - R-348
Recommendation 10: Ensure providers who violate Medicaid or other health insurance program provisions are subject to appropriate and timely sanctions, including removal from the Medicaid program.
Related finding F-384 - R-339
Recommendation 1: Review the $11.8 million in overpayments, disenroll the members from managed care plans, and make recoveries, as appropriate.
Related finding F-376 - R-340
Recommendation 2: Review the $1,002,504 in overpayments and make recoveries, as appropriate.