Department of Health

Medicaid Overpayments for Non-Emergency Out-of-State Inpatient Services

In New York State’s Medicaid program, the reimbursements paid to out-of-State providers of non-emergency inpatient services should be limited to certain amounts. In addition, such out-of-State medical services may require the prior approval of the Department of Health. However, when we examined the payments that were made over a seven-year period to two samples of such out-of-State providers, we found that the providers were usually overpaid and the required prior approval often was not obtained. Specifically, we determined that as much as $9.2 million of $13.2 million in selected payments was overpaid, and the required prior approval had not been obtained for $10.8 million of $15.9 million in selected payments. We recommended that the Department of Health investigate the $9.2 million in potential overpayments, recover all actual overpayments, and develop controls for preventing such overpayments in the future.

For a complete copy of Report 2009-S-35 click here.