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Office of the New York State Comptroller

Taxpayers' Guide to State and Local Audits

Department of Health
Medicaid Claims Processing Activity October 1, 2010 through March 31, 2011


Issued: April 18, 2012
Link to full audit report 2010-S-65

Purpose
To determine whether the Department of Health's eMedNY system reasonably ensured that Medicaid claims were submitted by approved providers, were processed in accordance with requirements, and resulted in correct payments to the providers. The audit covered the period October 2010 through March 2011.

Background
The Department of Health (Department) administers the State's Medicaid program. Medicaid claims are processed and paid by an automated system, eMedNY, which is overseen by the Department. When Medicaid claims are processed by eMedNY, they are subject to various automated edits. The purpose of the edits is to determine whether the claims are eligible for reimbursement and the amounts claimed for reimbursement are appropriate. During the six-month period ended March 31, 2011, eMedNY processed approximately 174 million claims resulting in payments to providers of about $25 billion.

Key Findings

  • Auditors identified almost $6.3 million in overpayments resulting from:
    • claims that were inappropriately billed because of incorrect Medicare information;
    • claims for inpatient stays for high (intensive) levels of care that should have been based on less costly "alternate" levels of care;
    • claims with questionable payments for durable medical equipment rentals;
    • incorrect neonatal claims; and
    • claims with overpayments for transportation and vision care.
  • Auditors took steps to recoup or stop more than $3.2 million of these overpayments. Auditors also found 6 providers who were charged with abusing Medicaid, Medicare or other health insurance systems. The Department promptly terminated 2 of these providers, but the remaining 4were still under review.

Key Recommendations

  • We made 16 recommendations to the Department to recover the remaining inappropriate Medicaid payments and improve controls in the overpayment areas we identified.

Other Related Audits/Reports of Interest
Department of Health: Medicaid Claims Processing Activity October 1, 2009 through March 31, 2010 Report 2009-S-71
Department of Health: Medicaid Claims Processing Activity April 1, 2009 through September 30, 2009 Report 2009-S-21
Department of Health: Medicaid Claims Processing Activity October 1, 2008 through March 31, 2009 Report 2008-S-155
Department of Health: Medicaid Claims Processing Activity April 1, 2008 through September 30, 2008 Report 2008-S-70


State Government Accountability Contact Information:
Audit Director: Brian Mason
Phone:(518) 474-3271; Email: StateGovernmentAccountability@osc.state.ny.us
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236