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Office of the New York State Comptroller

Taxpayers' Guide to State and Local Audits

Department of Health
Overpayments of Claims for Selected Professional Services


Issued: April 23, 2012
Link to full audit report 2010-S-73

Purpose
To determine whether inappropriate Medicaid payments were made for selected providers who also received payments from Medicare. The audit primarily covers the period January 2010 – December 2011. We also reviewed certain claim payments and records for the period January 2006-December 2009.

Background
On December 3, 2009, the Department implemented an automated Medicare/Medicaid crossover system. It was designed to reduce problems with processing and paying claims involving Medicare, which have historically caused significant Medicaid overpayments. Prior to the crossover system, Medicaid relied on providers to self-report accurate information to eMedNY (Medicaid's claims processing and payment system) regarding how much Medicare paid and how much Medicaid owed for deductibles and coinsurance. With the new crossover system, providers no longer need to submit separate claims to both Medicare and Medicaid for services to individuals with both Medicare and Medicaid coverage. Rather, providers bill claims directly to Medicare. Medicare reimburses its portion to the provider and then the provider's claim information is automatically forwarded (crossed over) to eMedNY for the payment of deductible and coinsurance amounts.

Key Findings

  • Although the Department implemented the new automated crossover system in December 2009 to reduce Medicaid overpayments, it was flawed. As a result, we identified potential and actual overpayments of $100,387 for 12,715 duplicate claims that were billed by selected professional services such as podiatrists, physical therapists and occupational therapists during the calendar years 2010 and 2011.
  • We tested $6,794 (of the $100,387) in payments for 663 apparent duplicate claims billed between January 12, 2010 and August 9, 2010 by one podiatrist. In all instances, the Department paid both the podiatrist and the podiatrist's medical group for the same services. This occurred because redundant claims for the same service were submitted through the crossover system under the podiatrist's group provider identification number and then also billed directly to Medicaid using the provider's individual identification number.

Key Recommendations

  • Correct the flaw in the eMedNY claims processing system that allows duplicate payments of Medicare/Medicaid crossover claims submitted by medical groups and their individual providers.
  • Review the $100,387 in duplicate payments and recover funds where appropriate.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Payments for Medicare Part A Beneficiaries Report 2009-S-36
Department of Health: Medicaid Payments for Dual Eligible Individuals Report 2009-S-64


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