Department of Social Services
Department of Health

Monitoring of Multiple Medicaid Billings by Physicians

New York's Medicaid program is jointly administered by the Department of Social Services and the Department of Health. The physicians participating in Medicaid are paid a separate fee for each service provided to their patients. The payments are based on the procedure codes indicated on the claim forms submitted by the physicians to the Department of Social Services. If more than one procedure is performed on a patient, each procedure may be billed with a different procedure code. However, if certain combinations of procedure codes are billed, the physician will paid more than once for the same service. We examined the procedures used by the Department of Social Services and the Department of Health to protect against such duplicate payments. We found that, while procedures have been established to deter such inappropriate billings, additional procedures are needed to detect these billings. We identified as much as $6.9 million in inappropriate multiple billings that were not detected and were therefore paid. We recommend that these overpayments be recovered, and we identify specific procedures that can be used to detect and prevent such overpayments in the future.

For a complete copy of 95-S-49 click here.
For a copy of the 90-day response click here.