Department of Civil Service

New York State Health Insurance Program: Selected Radiological Claims (Follow-Up Review)

The Department of Civil Service administers health insurance programs for State and local government employees and their dependents. The primary program in the New York State Health Insurance Program is the Empire Plan, which provides services costing about $1.6 billion a year. In our prior audit report 96-S-64, we examined certain radiological claims paid over a four- year period by the Empire Plan. We determined that a number of claims were overpaid because multiple claims were submitted for complex medical procedures, rather than a single claim as required. We estimated that these overpayments totaled at least $1.35 million. We recommended that the overpayments be recovered and improvements be made in the procedures designed to detect such erroneous claims. In our follow-up review, we found that most of the overpayments have not been recovered, because the insurance company that processes the claims does not agree with our determination that the claims were overpaid.

For a complete copy of Report 98-F-57 click here.