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NYS Comptroller


Taxpayers' Guide to State and Local Audits

Department of Health
Medicaid Payments to Medicare Advantage Plan Providers (Follow-Up)

Issued: October 15, 2019
Link to full audit report 2019-F-29
Link to 30-day response

To determine the extent of implementation of the three recommendations made in our initial audit report, Medicaid Payments to Medicare Advantage Plan Providers (Report 2016-S-54).

About the Program
Many of the State’s Medicaid recipients are also enrolled in Medicare, the federal health insurance program for people age 65 and older and people under 65 who have certain disabilities. Under Medicare Part C, private managed care companies administer Medicare benefits and offer different health care plans (Medicare Advantage plans) tailored to the specific needs of beneficiaries. For individuals enrolled in Medicaid and Medicare, providers bill Medicaid for the enrollee’s Part C cost-sharing liabilities (deductibles, coinsurance, and copayments).

We issued our initial audit report on September 10, 2018. The audit objective was to determine whether Medicaid inappropriately paid for recipients’ Medicare Part C cost-sharing liabilities. The audit covered the period January 1, 2012 through December 31, 2016. The initial audit identified $770,935 in Medicaid overpayments for Medicare Part C cost-sharing. The overpayments occurred because providers reported inflated Part C cost-sharing amounts on claims and the Department of Health (Department) lacked sufficient controls to detect and prevent such claims. Three providers in our review received significant overpayments. We analyzed all other Part C cost-sharing claims billed by these providers and identified potential additional overpayments of $562,356. We recommended the Department recover the inappropriate payments, advise the three providers how to properly bill Medicaid for Medicare Part C cost sharing, and prevent inappropriate claims going forward.

Key Finding
Department officials made some progress in addressing the problems we identified in the initial audit report. However, no action had been taken to recover the inappropriate payments we identified. Of the initial report’s three audit recommendations, one was not implemented and two were partially implemented.

Key Recommendation
Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

State Government Accountability Contact Information:
Audit Director: Andrea Inman
Phone: (518) 474-3271; Email:
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236