DiNAPOLI: AUDIT FINDS UP TO $12.1 MILLION IN INAPPROPRIATE MEDICAID PAYMENTS FROM COMPTROLLER’S OFFICE

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New York state’s Medicaid system made as much as $12.1 million in inappropriate payments during 2015, including $2.3 million for dead patients and millions more for recipients who had been dropped from long term care coverage, according to an audit released Tuesday by State Comptroller Thomas P. DiNapoli. By the end of audit fieldwork, about $2.1 million of the overpayments were recovered.

“My auditors continue to find glitches in the Department of Health’s payment control systems that allow wasteful payments to be made,” DiNapoli said. “The department agreed with most of our recommendations and is working to fix the problems we have uncovered. It should recover up to $10 million that should not have been spent.”

New York’s Medicaid program, administered by the state Department of Health (DOH), is a federal, state, and locally funded program that provides a wide range of medical services to those who are economically disadvantaged or have special health care needs. DOH’s eMedNY computer system processes Medicaid claims submitted by providers for services rendered to Medicaid-eligible recipients and generates payments to reimburse the providers for their claims. DiNapoli’s office audits Medicaid payments on a routine basis to make sure claims are being paid appropriately and to determine if improvements are needed and whether money should be recovered because of errors, abuse or fraud. In 2015, DiNapoli’s auditors questioned $223 million in payments.

Managed Long-Term Care (MLTC) plans provide services to recipients who have a long-lasting health problem or disability. Medicaid pays MLTC plans a monthly payment for every recipient enrolled in an MLTC plan. According to the department’s MLTC contract, DOH has the right to recover capitation payments made to plans for recipients who it is later determined were inappropriately enrolled because of death, incarceration, or relocation out of the plan’s service area. From Feb. 1, 2015 to Sept. 30, 2015, Medicaid made 1,745 capitation payments totaling more than $7.1 million for 1,324 recipients who were retroactively disenrolled from a plan by DOH or local Departments of Social Services.

With the enactment of the federal Patient Protection and Affordable Care Act (PPACA) in 2010, the state developed New York State of Health (NYSOH) as a new online marketplace for individuals to obtain health insurance coverage, including Medicaid. The PPACA requires NYSOH to verify an applicant’s identifying information when determining Medicaid eligibility and enrollment. Once individuals are enrolled in Medicaid, NYSOH is required to periodically verify recipients are alive to ensure active coverage is appropriate.

DiNapoli’s auditors determined NYSOH enrolled 119 deceased individuals into the Medicaid program, and NYSOH did not automatically terminate 1,177 enrollees who apparently died after enrollment. Medicaid overpaid 4,892 claims totaling $2,282,626 on behalf of 966 enrolled recipients. At the end of our fieldwork, 766 of the 1,296 deceased enrollees still had active Medicaid coverage through NYSOH. DOH subsequently completed its review of the 766 enrollees, concluded that 4 individuals were alive and took the necessary steps to close the accounts of the remaining 762 enrollees.

DiNapoli’s auditors also found:
· $1,052,058 in overpayments for claims billed with incorrect information pertaining to other health insurance coverage that recipients had;
· $813,412 in overpayments for low-birth weight newborn claims that were submitted with incorrect birth weights;
· $708,016 in overpayments for inpatient claims that were billed at a higher level of care than what was actually provided; and
· $77,861 in improper payments for duplicate billings and claims for clinic, transportation, durable medical equipment, and eye care services.

Auditors also identified providers in the Medicaid program who were charged with or found guilty of crimes that violate health care programs’ laws or regulations. DOH terminated 26 of those providers, but the status of five other providers was still under review at the time fieldwork was completed. DiNapoli made 11 recommendations to DOH to recover the remaining inappropriate Medicaid payments and improve claims processing controls. DOH generally agreed with the audit recommendations and indicated that certain actions have been and will be taken to address them. The agency’s complete response is included in the final audit.

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