Department of Civil Service

New York State Health Insurance Program: Inappropriate Billings for Outpatient Consultation Services

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.

We examined the payments made by the Empire Plan over a three-year period for outpatient consultation services to determine whether the payments were supported by the service providersí medical records. We found that 77 of the 284 claims in our random statistical sample were not supported by the medical records. In most of these instances, the records supported a less costly medical service than the consultation service that was claimed. On the basis of our sample results, we estimated that the Empire Plan overpaid service providers between $10.5 million and $17.5 million in our three-year audit period. We recommended that the Empire Planís insurer review other consultation service claims from this period, determine whether any of those claims were overpaid, and recover all identified overpayments. We also recommended that the insurer strengthen its controls to prevent future overpayments of this kind.

For a complete copy of Report 2007-S-20 click here.
For a copy of the 90-day response click here.