Purpose

To determine whether the Department of Health’s eMedNY system reasonably ensured that Medicaid claims were submitted by approved providers, were processed in accordance with Medicaid requirements, and resulted in correct payments to the providers. The audit covered the period April 1, 2013 through September 30, 2013.

Background

The Department of Health (Department) administers the State’s Medicaid program. The Department’s eMedNY computer system processes Medicaid claims submitted by providers for services rendered to Medicaid-eligible recipients, and it generates payments to reimburse the providers for their claims. During the six-month period ended September 30, 2013, eMedNY processed about 188 million claims, resulting in payments to providers of about $25 billion. The claims are processed and paid in weekly cycles, which averaged about 7.2 million claims and $964 million in payments to providers.

Key Findings

Auditors identified over $5.6 million in inappropriate or questionable Medicaid payments, including:

• $1,822,467 in payments for pharmacy claims that posed patient safety concerns or were not in compliance with regulations and policies necessary for payment of the claims;
• $1,826,725 in overpayments for inpatient claims that providers billed at higher levels of care than what was actually provided;
• $1,005,176 in overpayments for claims billed with incorrect information pertaining to recipients’ other health insurance coverage;
• $666,992 in overpayments for claims involving other insurance adjustment amounts that eMedNY incorrectly processed; and
• Claims with improper payments for hospital services, duplicate billings, and physician-administered drugs.

By the end of the audit fieldwork, auditors recovered about $2.3 million of the overpayments identified.

Auditors also identified providers in the Medicaid program who were charged with or found guilty of crimes that violate health care programs’ laws or regulations. The Department terminated 18 of the providers we identified, but the status of six other providers was still under review.

Key Recommendations

We made 15 recommendations to the Department to recover the remaining inappropriate Medicaid payments and improve claim processing and monitoring controls.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Claims Processing Activity April 1, 2012 Through September 30, 2012 (2012-S-24)
Department of Health: Medicaid Claims Processing Activity October 1, 2012 Through March 31, 2013 (2012-S-131)