Department of Civil Service

New York State Health Insurance Program: Duplicate Inpatient Claim Payments

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 more than $1.6 billion a year. In the Empire Plan, insurance coverage for medical, surgical and hospital services is provided by two insurance carriers. We examined certain types of medical claims paid by one of the insurance carriers to determine whether these payments duplicated payments made by the other insurance carrier. We identified a number of duplicate payments and estimate that, during the three years covered by our audit, these duplicate payments totaled between $3.5 and $4.0 million. We recommend improvements in the practices used to process these types of claims and to coordinate the coverage provided by the two insurance carriers. We note that duplicate payments of this kind were identified by our prior audit in 1993; however, our recommendations for improved claims processing and coordination were not fully implemented.

For a complete copy of Report 98-S-14 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.