Department of Health

Medicaid Claims Processing for the Six Months Ended September 30, 2009

Medicaid claims are processed and paid by an automated system (eMedNY) that is operated by a contractor and overseen by the Department of Health. We performed audit work related to the system and the payments made during the six months ended September 30, 2009, and concluded that eMedNY reasonably ensured that Medicaid claims were submitted by approved providers, were processed in accordance with requirements, and resulted in correct payments to the providers. However, we also identified certain areas where improvements were needed.

For example, we found that eMedNY could reimburse vision care providers for treating the same Medicaid recipient more times than is allowable over a two-year period. We identified ten affiliated vision care providers in Brooklyn that exploited this control weakness to repeatedly bill for excess services, some of which may not actually have been provided. We also determined that the providers may have been colluding in their inappropriate billing practices. We expanded our review of the payments to these ten providers and recommended that the Department of Health review all $3.2 million in such payments, and recover all inappropriate payments.

We also identified, or helped to prevent, other inappropriate Medicaid payments to other types of medical providers. We recommended that the Department recover the inappropriate payments, remove certain providers from the Medicaid program, and improve the controls over the payments in these areas.

For a complete copy of Report 2009-S-21 click here.