Department of Civil Service

New York State Health Insurance Program: Duplicate Payments for Evaluation and Management Procedures (Follow-Up Report)

In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for active and retired State, local government and school district employees and their dependents. The primary such program is the Empire Plan, which provides services costing about $4 billion a year.

In audit 2005-S-59, we examined payments made by the Empire Plan over a six-month period for evaluation and management services to determine whether any of the services were reimbursed more than once. We identified a number of instances in which the same service was reimbursed more than once and estimated that, during the six-month period, the erroneous payments totaled about $334,000. The erroneous payments were made because new computer software installed by the Empire Planís insurance carrier (United HealthCare) caused certain charges to be duplicated and errors in bills submitted by medical service providers were not always detected by the carrier. Insurance carrier officials knew that the new software was causing certain charges to be duplicated, but did not inform the State of the problem and did not attempt to identify and recover the overpayments. We recommended that the overpayments be recovered, improvements be made in the bill processing procedures of the insurance carrier, and all such problems be promptly reported to the State in the future. When we followed up on this matter, we found that some actions had been taken to implement our recommendation, but additional actions were needed.

For a complete copy of Report 2007-F-42 click here.