ALBANY, N.Y. — The New York State Department of Health (DOH) made $965 million in Medicaid payments to providers, including facilities, for services ordered, prescribed, referred, and attended by practitioners who were not enrolled in the health-care program, including those who had been barred due to misconduct. That’s according to an audit that New York State […]
ALBANY, N.Y. — The New York State Department of Health (DOH) made $965 million in Medicaid payments to providers, including facilities, for services ordered, prescribed, referred, and attended by practitioners who were not enrolled in the health-care program, including those who had been barred due to misconduct.
That’s according to an audit that New York State Comptroller Thomas DiNapoli released April 19.
Two other audits issued that same day found an additional $17 million in overpayments, his office added.
“Medicaid is a critically important program, but its payment system is rife with errors,” DiNapoli said. “My auditors found the system was allowing payments on claims involving providers who were not certified to treat Medicaid patients. This not only costs taxpayers, but also allows providers who should be excluded, and may be unqualified, to treat patients. DOH must improve its efforts to fix the shortcomings with its billing system.”
The New York State Medicaid program provides a range of medical services to low-income New Yorkers or to those who have special health-care needs. For the state fiscal year that ended March 31, 2021, New York’s Medicaid program had about 7.3 million recipients and Medicaid claim costs totaled $68.1 billion.
Auditors found eMedNY — DOH’s Medicaid claims processing system — allowed improper payments for services involving ordering, prescribing, referring, and attending providers who were no longer actively enrolled in the Medicaid program at the time of the service.
The “improper” payments included $5.8 million for services involving providers who were excluded from participating in Medicaid due to past improper behavior or wrongdoing.
The audit covered the period of January 2015 to December 2019. DiNapoli noted DOH made changes to eMedNY in February 2018, which led to a “significant drop” in the number of improper payments.
However, for the period of March 2018 through December 2019, auditors still identified about $45.6 million in claim payments for 135,476 services by ineligible providers, his office said.
DiNapoli’s auditors noted that when inactive providers are included on Medicaid claims, DOH “lacks assurance” those providers can furnish such services, and it increases the risk that excluded, or otherwise unqualified, providers are treating Medicaid enrollees.
Recommendations
DiNapoli recommended DOH review the $965 million in payments for Medicaid claims involving inactive providers and determine an appropriate course of action.
He also suggested the department enhance controls to prevent improper Medicaid payments for claims that do not report an active provider and that it update guidelines to clarify billing requirements.
Department officials “generally agreed” with most of the audit recommendations and indicated that “certain actions have been and will be taken to address them,” per DiNapoli’s office.
DOH’s full response is included in the audit, which is available at the website of the New York State Comptroller’s office.
