Department of Civil Service

New York State Health Insurance Program: Coding Fragmentation Review Program (Surgical Claims)

The Department of Civil Service administers health insurance programs for State and local government employees and their dependents. The primary such program is the Empire Plan, which provides services costing more than $1.6 billion a year. We examined certain surgical claims paid over a three-year period by the Empire Plan and found that some of the claims were overpaid. The claims were overpaid because multiple claims were submitted for complex medical procedures, rather than a single claim as required. We estimate that these overpayments totaled at least $865,000. We recommend that the overpayments be recovered and improvements be made in the procedures designed to detect such erroneous claims.

For a complete copy of Report 95-S-88 click here.
For a copy of the associated follow-up report click here.
For a copy of the 90-day response click here.