Department of Civil Service

New York State Health Insurance Program: Skilled Nursing Facility Claims (Follow-Up Review)

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 $1.5 billion a year. If Empire Plan enrollees are eligible for Medicare, their expenses for skilled nursing facility care should generally be paid by Medicare. In our prior audit report 96-S-26, we reviewed selected claims for skilled nursing facility care paid over a 63-month period by the Empire Plan and determined that about $365,000 of these claims should have been paid by Medicare. We recommended that these payments be recovered from Medicare, and that improvements be made in the Empire Plan's procedures for identifying enrollees who are eligible for Medicare. In our follow-up review, we found that most of the erroneous payments have yet to be recovered, and while some improvements have been made in the Empire Plan's procedures for identifying enrollees who are eligible for Medicare, further improvements are needed.

For a complete copy of Report 97-F-34 click here.
For a copy of the 90-day response click here.