New York State Health Insurance Program

 

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NYS Comptroller

THOMAS P. DiNAPOLI

Taxpayers' Guide to State and Local Audits

New York State Health Insurance Program
Empire BlueCross BlueShield Selected Payments for Special Items Made to Stony Brook University Hospital from January 1, 2011 through March 31, 2011


Issued: February 1, 2013
Link to full audit report 2012-S-53

Purpose
To determine if Empire BlueCross BlueShield's (Empire's) payments to State University of New York's Stony Brook University Hospital (Stony Brook) for special items were made according to the provisions of the agreement between Empire and Stony Brook.

Background
The New York State Health Insurance Program (NYSHIP) provides health insurance coverage to active and retired State, participating local government and school district employees and their dependents. The Empire Plan (Plan) is the primary health benefits plan for NYSHIP. The Department of Civil Service contracts with Empire to administer the hospitalization portion of the Plan. Empire processes Plan claims for hospital services in accordance with agreements they negotiate with member hospitals, including Stony Brook. Empire's payments to Stony Brook are generally based on standard fee schedules. However, Stony Brook is entitled to additional payments for certain special items (such as implants, drugs, and blood) that are not covered by the standard fee schedules. Per Empire's agreement with Stony Brook, the amounts of claims for special items should be related to Stony Brook's costs to acquire them.

Key Findings

  • We reviewed six claim payments (totaling $227,787) to Stony Brook for special items and determined Empire overpaid them by $78,452.

Key Recommendations

  • Recover the $78,452 from Stony Brook for the overpayments we identified in this audit.
  • Develop and implement the controls necessary to ensure that payments for special items comply with the terms of Empire‚Äôs contract with Stony Brook.

Other Related Audits/Reports of Interest

New York State Health Insurance Program: Payments Made to Stony Brook University Medical Center (2009-S-27)
New York State Health Insurance Program: Payments for Selected Items to Selected Hospitals (2010-S-74)


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