Department of Civil Service

New York State Health Insurance Program: Payments of Non-Participating Provider's Facility Fee Claims

In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for active and retired State, local government and school district employees and their dependents. The primary such program is the Empire Plan. The Department of Civil Service contracts with United HealthCare to process and pay medical claims for services provided to Empire Plan members. Members may choose to receive services from non-participating providers. United HealthCare is contractually obligated to apply cost limits when it pays billings from non-participating providers. We found that United did not apply the cost limitations when it processed facility fee claims submitted by non-participating providers until August 1, 2007. This resulted in United HealthCare overpaying such claims and, therefore, should refund $4.4 million to the State.

For a complete copy of Report 2007-S-110 click here.
For a copy of the associated follow-up report click here.