Medicaid Audit Intelligence

NY · Medicaid jurisdiction

New York Medicaid audit evidence

Review reports connected to New York Medicaid oversight, ordered by publication date.

Evidence register

12 reports

Published
Jul 16, 2026
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller Division of State Government Accountability
Report ID
REPORT 173

Medicaid Program – Improper Payments for Laboratory and Related Services

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…

Findings
1
Recommendations
8
Open evidence record
Source status
Original source
Published
Jun 4, 2026
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 174

Oversight of Services for Medicaid Members Enrolled in Clinical Trials

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…

Findings
4
Recommendations
3
Open evidence record
Source status
Original source
Published
Jan 20, 2026
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 172

Medicaid Program – Oversight of Health Homes

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…

Findings
4
Recommendations
7
Open evidence record
Source status
Original source
Published
Oct 22, 2025
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 123

Medicaid Program: Oversight of Managed Care Provider Networks

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…

Findings
5
Recommendations
3
Open evidence record
Source status
Original source
Published
Sep 9, 2025
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 124

Medicaid Program: Improper Premium Payments Made on Behalf of Managed Care Members Residing Outside the State

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…

Findings
12
Recommendations
11
Open evidence record
Source status
Original source
Published
Jun 18, 2025
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 54

Medicaid Program: Claims Processing Activity April 1, 2024 Through September 30, 2024

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…

Findings
6
Recommendations
7
Open evidence record
Source status
Original source
Published
Dec 4, 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 52

Medicaid Program: Overpayments for Medicare Part C Claims

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…

Findings
5
Recommendations
8
Open evidence record
Source status
Original source
Published
Nov 13, 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 103

Medicaid Program: Provider Compliance With the Electronic Visit Verification Program

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…

Findings
6
Recommendations
11
Open evidence record
Source status
Original source
Published
Feb 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 53

Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 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…

Findings
9
Recommendations
10
Open evidence record
Source status
Original source
Published
Feb 23, 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller
Report ID
REPORT 171

Medicaid Program: Improper Payments for Drugs Without a Federal Drug Rebate Agreement

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…

Findings
4
Recommendations
4
Open evidence record
Source status
Original source
Published
Apr 5, 2023
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 115

Medicaid Program: Maximizing Drug Rebates Under the Federal Medicaid Drug Rebate Program

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.

Findings
9
Recommendations
12
Open evidence record
Source status
Original source
Published
Dec 28, 2020
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 89

Medicaid Program: Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare

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…

Findings
10
Recommendations
9
Open evidence record
Source status
Original source