Purpose

To determine the extent of implementation of the five recommendations made in our audit report, Overpayments of Ambulatory Patient Group Claims (Report 2011-S-43).

Background

In 2008, changes to the State’s Public Health Law required a new Medicaid outpatient payment methodology (known as Ambulatory Patient Groups [or APG]) for clinic and ambulatory surgery services as well as hospital-based emergency room services. Our initial audit report, which was issued on August 20, 2013, identified flaws in the Department of Health’s eMedNY claims processing system that allowed improper payments on 6,615 claims (totaling Medicaid payments of $1,204,186). Auditors also identified $933,399 in duplicate payments that were made to providers for the same services under both the old and the new (APG) payment methodologies. Furthermore, we identified 56,241 claims totaling $4,286,603 that were at risk of duplicate payment and needed to be reprocessed using the new APG methodology. We made five recommendations to the Department of Health to review and recover the improper Medicaid payments and implement new claims processing controls to prevent future improper payments.

Key Finding

• Department of Health officials made significant progress in implementing the recommendations we made in our initial audit, which included recovering nearly $898,000 in overpayments and implementing new claims processing controls to prevent future improper payments. Of the initial report’s five audit recommendations, four were implemented and one was partially implemented.

Key Recommendation

• Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

Other Related Audit/Report of Interest

Department of Health: Overpayments of Ambulatory Patient Group Claims (2011-S-43)