Department of Health

Controls Over eMedNY Edit Changes

Medicaid claims in New York State are processed and paid by the automated eMedNY system. When the claims are processed by eMedNY, they are subject to various automated edits which determine whether the claims are eligible for reimbursement at the amounts claimed. The edits are to be programmed in accordance with instructions provided by various units within the Department of Health.

We examined the management controls over these edits and found that improvements were needed. For example, an unstructured and informal approach was often taken to the edit change process, as control responsibilities were not clearly understood and much of the process was not documented. In addition, edit changes were not always properly coordinated among the responsible Department units, were not always appropriately authorized, and were not always programmed as intended. Also, edits were not monitored after they were activated to ensure that they were functioning as intended, and they were not deactivated when they were no longer needed.

As a result of these control weaknesses, inappropriate Medicaid payments may not be prevented and Medicaid claims may be processed inefficiently. Our audits of specific Medicaid claims processing activities have identified numerous instances in which Medicaid overpayments were not prevented because of weaknesses in the edit management process. For example, in 2007 alone, our reports identified about $54.5 million in such overpayments. We made a number of recommendations for strengthening the Departmentís controls over the eMedNY edit process.

For a complete copy of Report 2007-S-139 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.