Comptroller says illegitimate payments cost Medicaid program over $1.5B

Regional News

FILE: $100 bills. (NEXSTAR)

ALBANY, N.Y. (NEWS10)- More than $1.5B in illegitimate payments were made by Medicaid over several years because of billing system errors, New York State Comptroller, Thomas DiNapoli said Tuesday.

He accused the Department of Health (DOH) of allowing the payments and possibly allowing unqualified or uncredentialed health care providers to care for patients using Medicaid.

“By not fixing problems with the Department of Health’s eMedNY system and other issues, hundreds of millions of dollars more in taxpayer dollars could be misspent and unqualified providers could continue to treat Medicaid patients. The department must act on our recommendations and address these shortfalls, so Medicaid recipients receive the level of care they deserve, and taxpayers’ dollars are spent effectively,” DiNapoli said.

Details of the findings are in three separate reports released by the Comptroller’s office. Key findings of the reports include:

  • Processing weaknesses in the Medicaid claims processing and payment system (eMedNY), allowed $1.5B in payments for Medicaid clinic and professional claims without an appropriate National Provider Identifier (NPI)
  • $57.3M in payments for pharmacy claims that did not contain an appropriate prescriber NPI
  • $19.4 million in payments for pharmacy claims that contained an NPI but, according to regulations, should not be included on Medicaid claims or that should be further reviewed by DOH
  • Claims totaling $28.5M paid for Medicaid recipients who were reported as discharged from a hospital then admitted to a different hospital less than 24 hours later, suggesting the first hospital incorrectly recorded a patient’s transfer as a discharge, a red flag that the claims are at a high risk of overpayment
  • Nearly half of the claims auditors sampled (15 of 31) were incorrectly coded as discharges in the eMedNY system, resulting in an overpayment of $252,107, or 55% of the total value of the 31 sampled claims. Auditors also found that DOH has no process to identify and recover such improper Medicaid payments.
  • DOH made progress addressing problems identified in the initial audit report and the Office of the Medicaid Inspector General recovered $50.8M of the $102.1M identified, another $51.3M still needs to be recovered.
  • Auditors identified another $14.3M in managed care premium payments for 14,293 potentially inappropriate identification numbers for the period July 1, 2018, to August 31, 2020.

In its response to the Comptroller’s reports, DOH said it was working on various solutions to correct issues and implement recommendations made by the Comptroller. All three reports are below.

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