New York State Health Insurance Program

 

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Office of the New York State Comptroller

Taxpayers' Guide to State and Local Audits

New York State Health Insurance Program
Overpayments for Claims Submitted by Nanuet Medical Services - Follow-Up (Issued 1/10/12)


Purpose
To determine if the recommendations made in our initial audit report New York State Health Insurance Program: Overpayments for Claims Submitted by Nanuet Medical Services (Report 2009-S-1) issued on July 28, 2009,were implemented.

Background
The New York State Health Insurance Program (NYSHIP) administers health insurance programs for State, local government, and school district employees, retirees, and their families.  The Empire Plan is the primary program for NYSHIP. The United HealthCare Insurance Company processes and pays claims from health care providers for services rendered to Empire Plan members.  Nanuet Medical Services provides chiropractic and physical therapy to Empire members in Rockland County.

During the 47-month period ended November 30, 2008, United HealthCare overpaid Nanuet $601,600.  The overpayments occurred because United HealthCare’s claims processing system did not have controls to limit the number of times a transcutaneous electrical nerve stimulation (TENS) service can be paid for a single individual.  We recommended United HealthCare recover the overpayments and implement controls to limit payments for TENS services to only legitimate claims.

Key Findings

  • United has made significant progress in correcting the problems we identified in the initial report.  United implemented controls to stop inappropriate claims for TENS services from paying, and United is pursuing recovery of the overpaid amounts.
  • United identified an additional $359,700 in overpayments that occurred outside of our audit scope period.  Therefore, United is pursuing recovery of $961,300, including the $601,600 identified in our initial report and the additional $359,700 identified by United.

Key Recommendations

  • Complete planned actions to recover overpayments.

Link to full audit report (2011-F-23)

Other Related Audits/Reports of Interest
NYSHIP: Overpayments for Claims Submitted by Albany Multi-Medicine Group (Report 2008-S-177)
NYSHIP: Overpayments for Claims Submitted by TotalCare Medical PC (Report 2008-S-178)
NYSHIP: Overpayments for Claims Submitted by Nanuet Medical Services (Report 2009-S-1)


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