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NYS Comptroller

THOMAS P. DiNAPOLI

Taxpayers' Guide to State and Local Audits

Department of Health
Unnecessary Managed Care Payments for Medicaid Recipients with Medicare
(Follow-Up)

 


Issued: November 01, 2013
Link to full audit report 2013-F-15
Link to 30-day response

Purpose
To determine the extent of implementation of the six recommendations included in our initial audit report, Unnecessary Managed Care Payments for Medicaid Recipients with Medicare (Report 2010-S-75).

Background
Our initial audit report, which was issued on April 18, 2012, examined whether the Department of Health (Department) made premium payments to Medicaid managed care plans for Medicaid recipients who also had Medicare health insurance coverage, known as "dual eligibles." For the three-year audit period ended May 31, 2010, we identified about 271,000 unnecessary Medicaid managed care payments (totaling about $111 million) that were made on behalf of 45,000 Medicare recipients who were ineligible for Medicaid managed care programs. Had Medicaid paid only the Medicare deductibles and coinsurance for the recipients in question, the net savings to Medicaid would have been about $36 million. The unnecessary Medicaid managed care premiums occurred because of delays in posting recipients' Medicare data to eMedNY (Medicaid's automated claims processing and payment system) and because recipients were not removed timely from the managed care plans once their Medicare data was posted to eMedNY. We recommended the Department assess the quality and utility of the Medicare eligibility data it uses and take action to improve data quality or develop alternate means to compensate for data deficiencies. We also recommended the Department actively monitor the efforts of the localities and the broker to remove Medicaid recipients from managed care programs when they become Medicare eligible, and to increase its direct efforts if necessary to remove these dual eligible persons. Furthermore, we recommended the Department add measurable performance standards to the broker agreement regarding timely removal of dual eligibles from Medicaid managed care programs, and to implement procedures to help ensure that Medicaid does not pay managed care premiums for enrollees of the Family Health Plus program who also have Medicare.

Key Finding

  • Department and Office of the Medicaid Inspector General officials have made progress in correcting the problems we identified in the initial report. However, improvements are still needed. Of the six prior audit recommendations, three were implemented, two were not implemented and one is no longer applicable.

Key Recommendations

  • None

Other Related Audit/Report of Interest

Department of Health: Unnecessary Managed Care Payments for Medicaid Recipients with Medicare (2010-S-75)


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