Photo: Will Waldron
ALBANY — An audit of the state’s Medicaid program found that certain types of claims were being processed incorrectly, resulting in more than $10 million worth of inappropriate or excess payments, the state comptroller’s office announced Thursday.
The audit covered from April through September 2017 and examined the state Health Department’s eMedNY computer system that processes Medicaid claims submitted by health care providers.
Over that six-month period, providers submitted 193 million claims and were reimbursed more than $31 billion. Most of the claims were processed and reimbursed correctly, but $10.2 million worth of claims were not, the comptroller’s office said, highlighting the need for improvements in processing certain types of claims, including:
- $3.7 million worth of claims that were billed with incorrect information related to other insurance that recipients had;
- $3.1 million in overpayments for Medicaid claims involving Medicare coverage;
- $1.3 million in incorrect newborn birth claims;
- $783,016 in inappropriate fee-for-service payments when the recipient had managed care;
- $684,457 in excess claims for the Comprehensive Psychiatric Emergency Program;
- $465,257 in improper episodic home health care payments; and
- $172,052 in other overpayments.
By the end of the audit fieldwork, about $4.5 million in overpayments were recovered, the report noted, and the Health Department said it will work with the Office of the Medicaid Inspector General to recoup the rest.
“The department stands by its extremely high rate of payment accuracy (99.7 percent of payments reviewed by the audit),” department spokeswoman Erin Silk said in an email. “As the audit points out, measures are currently in place to ensure that correct payments are made to qualified providers.”
Auditors also identified 51 health care providers who participate in the state Medicaid program and were charged with or found guilty of crimes that violate health care program laws and regulations. The Health Department terminated 42 of them.
There is some question of whether $292,681 that was paid to five of them from the time they were charged with a crime until they were terminated should be paid back. The comptroller’s office has recommended the department make a determination one way or the other.