Department of Health
Overpayments for Medicare
Part C Coinsurance Charges
Issued: September 26, 2012
Link to full audit report 2011-S-33
Purpose
To identify Medicaid overpayments made to medical providers for services rendered to recipients
enrolled in a Healthfirst Medicare Advantage Plan. The audit covers the period July 1, 2006
through September 30, 2011.
Background
Medicare Advantage Plans, also known as Medicare Part C (or Medicare Managed Care), are
health plan options available to Medicare enrollees. Persons who join a Medicare Advantage
Plan receive their Medicare benefits through a health plan, which has networks of participating
providers that the plan reimburses directly. Medicare Advantage Plan enrollees may be responsible
for cost-sharing liabilities such as deductibles and coinsurance. However, these liabilities may be
paid by Medicaid if the individual is also enrolled in Medicaid. When this occurs, plan providers
bill Medicaid directly for enrollees' cost-sharing liabilities.
Healthfirst is one of the largest Medicare Advantage organizations in New York, offering individuals
different health care options under several Medicare Advantage Plans. During the audit period,
Medicaid paid about 64,000 Medicaid claims (totaling $5.6 million) for clinic services provided to
persons enrolled in a Healthfirst Medicare Advantage Plan.
Key Findings
- Healthfirst misreported the cost-sharing liabilities of Medicaid recipients to some of its healthcare providers. As a result, 14 providers billed excessive amounts of coinsurance on 497 Medicaid claims for clinic services. Because of the excessive claims, Medicaid made overpayments totaling $699,258 to the providers. Healthfirst has taken actions to prevent further errant claims and overpayments.
- As a result of our audit, plan providers submitted claim adjustments to reimburse Medicaid for some of the overpayments we identified. At the time our audit fieldwork was completed, providers submitted adjustments for 126 (of the 497) errant claims, and Medicaid had recovered $195,835.
Key Recommendations
- Review the remaining 371 errant claims and the related $503,423 in Medicaid overpayments identified in this report and recover funds where appropriate.
Other Related Audits/Reports of Interest
Department of Health: Medicaid Payments to Selected Providers for Services to Recipients with
Medicare Part C Coverage Report 2010-S-22
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
