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May 3, 2012


Comptroller DiNapoli Releases Audits

New York State Comptroller Thomas P. DiNapoli announced today the following audits have been issued:

New York State Health Insurance Program, Empire BlueCross and BlueShield
Payments to John T. Mather Memorial Hospital (2010-S-51)

The Long Island Health Network (Health Network) is comprised of ten hospitals, including John T. Mather Memorial Hospital (Mather). Empire's agreement with the Health Network allows the hospitals to be reimbursed for special items that are not included on Empire's standard rate schedules. Although the base hospital stay and related procedures covered under the agreement are reimbursed at rates prescribed in fee schedules, Mather can submit claims for certain items (not on fee schedules) separately as "special items." Auditors found Empire did not have appropriate controls to protect the state from excessive billings. As a result, Mather was allowed to substantially mark up the amounts billed. Auditors estimate Mather was reimbursed almost 300 percent of the purchase price for special items with an estimated total profit of $707,351 on 138 claims reviewed.

Department of Health, Overpayments of Claims for Selected Professional Services (2010-S-73)
Although the Department of Health implemented a new automated crossover system in December 2009 to reduce Medicaid overpayments, it was flawed. As a result, auditors identified potential and actual overpayments of $100,387 for 12,715 duplicate claims that were billed by selected professional services during the calendar years 2010 and 2011. Auditors tested $6,794 (of the $100,387) in payments for 663 apparent duplicate claims billed between January 12, 2010 and August 9, 2010 by one podiatrist. In all instances, the department paid both the podiatrist and the podiatrist's medical group for the same services. This occurred because redundant claims for the same service were submitted through the crossover system under the podiatrist's group provider identification number and then also billed directly to Medicaid using the provider's individual identification number.



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