Purpose

To determine whether the practice of Dr. John Gomes routinely waived Empire Plan members’ out-of-pocket costs, and if so, to quantify the overpayments made by United HealthCare (United) resulting from this practice. Our audit covered the period January 1, 2011 through September 30, 2014.

Background

The New York State Health Insurance Program (NYSHIP) provides health insurance coverage to active and retired State, participating local government and school district employees, and their dependents. The Empire Plan is the primary health benefits plan for NYSHIP. The New York State Department of Civil Service (Department) contracts with United to process and pay medical claims for services provided to Empire Plan members.

United contracts with certain providers who agree to accept payments, at rates established by United, to furnish medical services to Empire Plan members. United pays these “participating providers” directly based on claims they submit for the services rendered. Members pay a nominal co-payment to the participating provider for the services rendered. Members may also choose to receive services from “non-participating providers.” The claims from non-participating providers usually include service fee rates that are higher than the fee rates that participating providers agree to accept for the same services. Often, the rates for non-participating providers are much higher than the rates for participating providers. Consequently, to encourage members to use participating providers, the Empire Plan requires members to pay higher out-of pocket costs (including deductibles and co-insurance) when they use non-participating providers.

Participating providers agree to accept service fee rates that are generally lower than the fee rates for non-participating providers because service payments are made directly to the provider (instead of the member, as is the case for the payment of claims from non-participating providers). Therefore, participating providers avoid the problems related to the collection of large unpaid balances from patients.

Our audit focused on claims submitted by Women’s Healthcare - Garden City, an obstetrics and gynecology practice operated by Dr. John Gomes, located on Franklin Avenue in Garden City, New York. With respect to the Empire Plan, Dr. Gomes’ practice is a non-participating provider. During the period January 1, 2011 through September 30, 2014, United paid over $5 million for claims for services provided by Dr. Gomes to Empire Plan members.

Key Findings

• Dr. Gomes routinely failed to actively pursue the collection of out-of-pocket cost-sharing obligations from Empire Plan members and, as such, ostensibly waived the amounts in question. Such a practice may constitute billing fraud, as the Empire Plan typically reimbursed 80 percent of what it understood to be Dr. Gomes’ actual charges (including members’ out-of-pocket cost obligations).
• For example, Dr. Gomes billed $8,450 and United allowed $6,373 for certain services provided on January 6, 2011. United paid $5,228 on the related claim, and the member’s out-of-pocket portion of this claim should have been $1,144. However, Dr. Gomes accepted the $5,228 as payment in full and ostensibly waived the $1,144 due from the member. Because Dr. Gomes’ total payable charge was actually only $5,228, United should have paid Dr. Gomes only $4,084 on the claim, and therefore, he was overpaid by $1,144 ($5,228 - $4,084). In this case, nearly four years passed without any meaningful effort by Dr. Gomes to collect the amount otherwise due from the member. Therefore, we concluded that Dr. Gomes ostensibly waived the member’s out-of-pocket cost obligation.
• From a random sample, we identified overpayments amounting to $138,905, resulting from claims that were excessive and attributable to the routine waiving of members’ cost-sharing obligations. Using statistically valid methods, we projected the total amount of Dr. Gomes’ excessive claim payments to be $1,258,855 for the period January 1, 2011 through September 30, 2014.

Key Recommendations

• Recover from Dr. John Gomes $1,258,855 in overpayments funded by the State.
• Work with the Department of Civil Service to pursue an appropriate course of action designed to prevent Dr. John Gomes from waiving patients' out-of-pocket costs.  This may include taking steps to recruit Dr. Gomes into the Empire Plan participating provider network.

Other Related Audits/Reports of Interest

United Health Care: New York State Health Insurance Program - Overpayments for Services at the Capital Region Ambulatory Surgery Center (2007-S-72)
United Health Care: New York State Health Insurance Program - Overpayments for Services at the Day Op Center of North Nassau (2007-S-120)