Department of Civil Service

New York State Health Insurance Program: Claims for Surgical Procedures

In the New York State Health Insurance Program, 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 about $1.6 billion a year. We examined the claims paid over a three-year period by the Empire Plan for medical procedures related to surgeries. We found that duplicate payments were made because, in some instances, separate claims were submitted for medical procedures included in the overall cost of a patient's surgery. We estimated that these overpayments totaled at least $1.7 million. We recommend that the overpayments be refunded to the State by the insurance carrier and improvements be made in the insurance carrier's procedures for detecting such erroneous claims.

For a complete copy of Report 96-S-63 click here.
For a copy of the 90-day response click here.