Department of Social Services

Medicaid Medical Service Limitation Program

In New York's Medicaid program, needy people are treated by medical providers, who are in turn reimbursed by the Department. To ensure that reimbursements are paid for necessary services only, certain services may not be reimbursed more than a certain number of times a year without special authorization. For example, without special authorization, no more than 14 physician visits per year may be reimbursed for each patient. However, due to weaknesses in Department procedures for processing Medicaid claim forms, as well as errors by medical providers in submitting the claim forms, many of the services provided to Medicaid recipients are not taken into account when determining whether service limitations have been exceeded. For example, during a three-month period, we identified about 187,000 claims for a total of $12.5 million that were not taken into account when determining whether service limitations were exceeded. Because of these processing weaknesses and submission errors, the Department is less likely to prevent reimbursements for unnecessary or spurious services. 94-S-33