DOH did not provide adequate guidance to providers and MCOs, nor did it effectively monitor fee-for-service and managed care claims to ensure Medicaid paid only for necessary laboratory services. Weaknesses in DOH’s eMedNY system edits allowed improper fee-for-service laborato…
DOH did not always receive attestation forms prior to members participating in clinical trials, and a limited number of improper Medicaid payments related to investigational services or services not covered by the member’s MCO or lacking prior authorization were identified. DO…
DOH did not adequately oversee Medicaid Health Homes to ensure appropriate care and payments, including delays in redesignation reviews, noncompliance with policies, and lack of baseline measurements, with $19.7 million in payments lacking proper MAPP-based support; the agency…
DOH did not maintain sufficient oversight of Medicaid managed care provider networks during 2023, with data reliability and process control issues affecting the accuracy of deficiency reporting and SOAs, incomplete communication with MCOs, and potential cost exposure due to in…
DOH relied on PARIS to identify out-of-state residency but faced data gaps and processing flaws, leading to potentially billions in improper managed-care premium payments. The audit highlights multiple corrective actions, including expanding data sources (NCOA, Florida voter r…
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…
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 stren…
DOH’s EVV program showed significant control weaknesses and data quality issues, with large volumes of Medicaid payments made without matching EVV records and with low EVV-claim match rates (56% for PC and 11% for HHC). The VO pre-claim review requirement ended in January 2024…
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 catego…
The audit found that the Department’s oversight of Medicaid drug payments and the capitation rate adjustment process were inadequate, resulting in a substantial amount of improper MCO payments for drugs from manufacturers without an NDRA; the Department should revise the rate…
While the Department has made significant process improvements and system enhancements in the rebate collection process, certain weaknesses remain, resulting in $183.7 million in Medicaid drug rebates not invoiced during the audit period.
The Office of the Inspector General notes that it is not expressing an opinion on the State Comptroller’s report or its results; however, the OSC encourages CMS to consider the report and its results and work with state partners to ensure the federal share of improper Medicaid…