Department of Health

Medicaid Overpayments Relating to Managed Care

Many of New York’s Medicaid recipients are enrolled in managed care organizations (MCOs). If a recipient is enrolled in an MCO, the MCO pays for the medical services provided to the recipient, and Medicaid pays the MCO a fixed monthly capitation premium for each recipient enrolled in the MCO. If a Medicaid recipient is not enrolled in an MCO, Medicaid pays providers for services on a fee-for-service basis.

We examined certain payments made by Medicaid over a two-year period on behalf of recipients enrolled in MCOs and identified about $24.2 in unrecovered overpayments. About $15.3 million of these overpayments were caused by delays in updating managed care enrollment information (this information is supposed to be updated by local social services districts), while $8.9 million related to certain fee-for-service payments that were covered by the recipients’ MCOs. We also identified other potential overpayments, as $5.2 million in certain fee-for-service payments appeared to overlap the managed care coverage provided by $7.1 million in capitation premiums. We recommended that all overpayments be recovered and other actions be taken to prevent, or expedite the recovery of, future overpayments.

For a complete copy of Report 2001-S-44 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.