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
Upcoding of Selected Evaluation and Management Services (Follow-Up)


Issued: September 05, 2013
Link to full audit report 2013-F-13

Purpose
To determine if the recommendations made in our initial and follow up audit reports named New York State Health Insurance Program: Upcoding of Selected Evaluation and Management Services (2006-S-11) and our initial follow up to this audit (Report 2007-F-41) were implemented.

Background
The New York State Health Insurance Program (Program) provides health insurance coverage to active and retired State, participating local government and school district employees and their dependents. The Empire Plan is the primary health benefits plan for the Program. The New York State Department of Civil Service (Department) contracts with United HealthCare (United) to process and pay medical claims for services provided to Empire Plan members.

In our initial audit, we estimated United overpaid between $4,999,636 and $6,487,932 to providers who billed at a higher paying CPT code for an E/M service than the service actually performed. This practice is commonly referred to as upcoding.

Key Findings

  • Since the last time we followed up on the issue, United completed a major project to review claim payments for E/M services and identify upcoded claims.  As a result, United recovered over $1 million in overpayments.

Key Recommendations

  • None

Other Related Audits/Reports of Interest

New York State Health Insurance Program - Upcoding of Selected Evaluation and Management Services (2006-S-11)
New York State Health Insurance Program - Upcoding of Selected Evaluation and Management Services (Follow-up) (2007-F-41)


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