United HealthCare

New York State Health Insurance Program: Payments for Services at the Mackool Eye Institute and Laser Center

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.

The MacKool Eye Institute and Laser Center is located in Astoria, New York. The Center does not participate in the Empire Plan. Accordingly, if an Empire Plan member is treated by the Center, the Empire Plan will not reimburse the Center for its full charges. Rather, it will only reimburse a portion of these charges (generally 80 percent), and the member will have to pay the balance. Some medical providers routinely waive Empire Plan membersí out-of-pocket expenses, a practice that may constitute billing fraud because the providerís actual charges are overstated. We examined whether the Center was routinely waiving Empire Plan membersí out-of-pocket expenses, and found that it was not.

For a complete copy of Report 2008-S-29 click here.