Department of Civil Service

New York State Health Insurance Program: Hospital Inpatient Claims (Follow-Up Review)

In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for State and local government employees and their dependents. The primary such program is the Empire Plan, which provides services costing about $1.6 billion a year. In our prior audit report 95-S-87, we examined the hospitalization claims paid over a two- year period by the Empire Plan and found that certain claims were overpaid because incorrect reimbursement rates were used by the hospitals. We estimated that these overpayments totaled $705,895. Since the incorrect reimbursement rates should have been detected by the Empire Plan's insurance carrier (Empire Blue Cross Blue Shield), we recommended that the insurance carrier refund the overpayments to State. In our follow-up review, we found that the insurance carrier has not refunded the overpayments to the State and does not intend to refund the overpayments in the future. We have requested a legal opinion as to whether we can offset overpayments identified by NYSHIP audits against premium payments due insurance carriers.

For a complete copy of Report 98-F-15 click here.