Department of Civil Service

New York State Health Insurance Program: Payments Made to Stony Brook University Medical Center

The New York State Health Insurance Program (NYSHIP) provides health insurance coverage to active and retired State, local government and school district employees and their dependents. The Empire Plan (Plan) is the primary health benefits plan for NYSHIP. The Department of Civil Service (Department) contracts with Empire to administer the hospitalization portion of the Plan, which provides coverage for inpatient and outpatient services provided by a hospital or other eligible healthcare facility. Empire processes Plan claims for hospital services in accordance with agreements between Empire and member hospitals. For the five year period ending December 31, 2008, Empire paid 169,912 claims totaling $249.7 million for services provided by Stony Brook to Plan members. We identified 94 errors (44 percent) on 79 of the 179 random sample claims we selected for review. With few exceptions, the errors led to overpayments, many of which were significant. When we statistically projected these errors to the entire population of claim payments for the five-year audit period, the resulting estimate showed that the hospital had been overpaid by a total of about $3.7 million. We recommended that the carrier recover these overpayments from the hospital, and remit the $3.7 million to the State. We also recommended that the carrier establish controls to prevent such overpayments in the future.

For a complete copy of Report 2009-S-27 click here.