Department of Health

Controls Over eMedNY Edit Changes (Follow-Up)

Medicaid claims in New York State are processed and paid by the automated eMedNY system. When the claims are processed by eMedNY, they are subject to various automated edits which determine whether the claims are eligible for reimbursement at the amounts claimed. The edits are e programmed in accordance with instructions provided by various units within the Department of Health (Department).

In audit report 2007-S-139, we examined the management controls over these edits and found there were control weaknesses and improvements were needed. For example, edit changes were not always properly coordinated among the responsible Department units, were not always appropriately authorized, and were not always programmed as intended. As a result of these control weaknesses, inappropriate Medicaid payments may not be prevented and Medicaid claims may be processed inefficiently. For example, in 2007 alone, our audit reports identified about $54.5 million in overpayments. We made a number of recommendations for strengthening the Department's controls over the eMedNY edit process. When we followed up with Department officials, we found they have made progress in correcting some of the problems we identified in the initial report. However, improvements are still needed.

For a complete copy of Report 2011-F-4 click here.