Department of Civil Service

New York State Health Insurance Program: Overpayments for Services Provided by the Mount Kisco Medical Group, PC

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, which provides services costing more than $5 billion a year.

The Mount Kisco Medical Group (Mount Kisco) is a medical practice consisting of numerous primary and specialty care physicians with multiple locations in Westchester, Putnam and Dutchess Counties. Mount Kisco did not participate in the Empire Plan during our audit period. Accordingly, if an Empire Plan member was treated by Mount Kisco during this period, the Empire Plan did not reimburse Mount Kisco for its full charges. Rather, it only reimbursed a portion of these charges (generally 80 percent), with the member paying the balance. However, we found that Mount Kisco often waived Empire Plan membersí out-of-pocket expenses. Such a practice inappropriately inflated the Empire Planís reimbursement payment for the services, because the Empire Plan was reimbursing 80 percent of what it understood to be Mount Kiscoís actual charges for the services. We recommended the Empire Plan recover the inflated portion of Mount Kiscoís bills, an amount we calculated to be $190,655 for the five-year period we audited.

For a complete copy of Report 2009-S-22 click here.