New York State Health Insurance Program

 

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Office of the New York State Comptroller

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New York State Health Insurance Program
United HealthCare - Overpayments for Claims Submitted by TotalCare Medical PC (Follow-Up)


Issued: September 19, 2012
Link to full audit report 2012-F-23

Purpose
To determine if the recommendations made in our initial audit report New York State Health Insurance Program: United HealthCare - Overpayments for Claims Submitted by TotalCare Medical PC (Report 2008-S-178) issued on July 28, 2009,were implemented.

Background
The New York State Health Insurance Program (NYSHIP) provides health coverage to State, local government, and school district employees, retirees, and their dependents. The Empire Plan is the primary benefit plan for NYSHIP.  The Department of Civil Service contracts with United HealthCare (United) to process and pay medical claims from health care providers for covered services rendered to Empire Plan members.  TotalCare Medical PC (TotalCare) is located in Warren County and provides physical medicine treatments, such as chiropractic services and physical therapy, to Empire Plan members.

For the period January 1, 2004 through November 30, 2008, United overpaid TotalCare $248,202.  The overpayments occurred because United’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 recover the overpayments and implement controls to limit payments for TENS services to only legitimate claims.

Key Findings

  • United has made 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 $23,840 in overpayments that occurred outside of our audit scope period.  Therefore, United is pursuing recovery of $272,042, including the $248,202 identified in our initial report and the additional $23,840 identified by United.

Key Recommendations

  • Complete planned actions to recover overpayments and refund the amounts recovered to New York State.

Other Related Audits/Reports of Interest

New York State Health Insurance Program: Overpayments for Claims Submitted by TotalCare Medical, PC Report 2008-S-178
New York State Health Insurance Program: Overpayments for Claims Submitted by Nanuet Medical Services Follow Up Report 2011-F-23


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