Department of Social Services
Medicaid Payments for Medicare
Part B Services Medicare is a federal health insurance program for the
aged and the disabled, while Medicaid is a joint state and federal health insurance program for
the needy. If an individual is eligible for both Medicare and Medicaid, the costs covered by
insurance are paid by Medicare, except for a portion of the costs relating to certain services
(called Part B services), which are paid by Medicaid through Medicare crossover claims. We
examined the Medicare crossover claims paid by the Department of Social Services for
services provided by hospital-based clinics and freestanding clinics. We found that, because
of federal payment guidelines, hospital-based clinics are paid significantly more for the same
services than freestanding clinics. We estimated that, over a two-year period, these additional
payments cost New York's Medicaid program about $27 million. We recommend that
officials from the Department of Social Services try to change the federal payment guidelines.
We also examined the procedures used by the Department to process Medicare crossover
claims and found that, because of weaknesses in these procedures, inappropriate payments
were made. For example, because a misplaced decimal point on a claim form was not
detected, a hospital-based clinic was overpaid $7.5 million. We recommend that the
Department establish certain processing controls and recover the overpayments identified.
For a complete copy of 95-S-40 click here.
For a copy of the 90-day response click here.