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 October 1, 2013 through March 31, 2014.

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 March 31, 2014, eMedNY processed about 112 million claims, resulting in payments to providers of about $25 billion. The claims are processed and paid in weekly cycles, which averaged about 4.3 million claims and $973 million in payments to providers.

Key Findings

Auditors identified about $3.3 million in inappropriate Medicaid payments, including:

• $1,335,151 in overpayments for hospital claims for which eMedNY did not properly factor Medicare coverage or a lower level of care into the payment;
• $682,022 in overpayments for pharmacy claims that were not in compliance with various regulations and policies;
• $416,314 in improper payments for claims that were not subjected to the appropriate claims processing logic in eMedNY;
• $360,117 in overpayments for claims with incorrect information pertaining to other health insurance coverage that recipients had;
• $112,981 in overpayments for nursing home claims for which eMedNY did not correctly deduct the recipients’ Net Available Monthly Income (NAMI); and
• Claims with improper payments for duplicate billings and hospital, clinic, transportation, and eye care services.

By the end of the audit fieldwork, auditors recovered about $2 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 12 of the providers we identified, but the status of four other providers was still under review.

Key Recommendations

We made 16 recommendations to the Department to recover the remaining inappropriate Medicaid payments and improve claim processing controls.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Claims Processing Activity October 1, 2012 Through March 31, 2013 (2012-S-131)
Department of Health: Medicaid Claims Processing Activity April 1, 2013 Through September 30, 2013 (2013-S-12)