Department of Civil Service
New York State Health Insurance Program: Overpayments for Claims Submitted by TotalCare Medical PC
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 more than $5 billion a year.
TotalCare Medical PC (TotalCare), which is located in Queensbury, is a group medical practice specializing in physical medicine services. During the three-year period covered by our audit, the Empire Plan paid $285,658 on claims submitted by TotalCare for a certain medical procedure that is intended to control pain (transcutaneous electrical nerve stimulation or TENS). We audited these claims and found that they were frequently miscoded, as routine physical therapy services should have been claimed instead of TENS. Since routine physical therapy services are reimbursed at a much lower rate than TENS, TotalCare was overpaid by a total of $248,202 (87 percent) on its TENS claims. We recommended that these overpayments be recovered and controls be developed to prevent such overpayments in the future.
For a complete copy of Report 2008-S-178 click here.
For a copy of the 90-day response click here.