Press Releases
CONTACT:
Press Office
(518) 474-4015

 FOR RELEASE:

Immediately
April 21, 2010



Comptroller DiNapoli Releases Audits

New York State Comptroller Thomas P. DiNapoli announced today the following audits have been issued:

Department of Health, Inappropriate Medicaid Payments for Community-Based Services While Recipients Resided in Nursing Homes (Follow-Up Report) (2008-F-33)
Community-based services are intended to help recipients live at home rather than in a residential health care facility, such as a nursing home. In audit 2006-S-106, auditors examined selected Medicaid payments for community-based services and nursing home services over a five-year period, and identified about $2.1 million in potentially inappropriate payments for community-based services. Auditors recommended that the Department of Health (DOH) investigate the potential overpayments, recover all overpayments, and develop controls to prevent future overpayments. When auditors followed up on these matters with DOH officials, they found DOH had taken some, but not all of the recommended actions.

Office of Children and Family Services, New York City Administration for Children's Services, New York City Human Resources Administration, Health, Safety and Fiscal Issues Relating to Legally-Exempt Child Care in New York City (Follow-Up Report) (2009-F-18)
Child care providers in New York State are licensed, registered and regulated under the supervision of the Office of Children and Family Services (OCFS). Under the New York State Child Care Block Grant subsidy program, child care providers that are legally-exempt from certain OCFS requirements are paid for child care services provided to children of eligible families. Two agencies jointly operate this program in New York City: the Administration for Children’s Services (ACS) and the Human Resources Administration (HRA).

In audit 2007-N-11, auditors examined whether oversight activities by OCFS, ACS and HRA were effective in monitoring the health and safety of children receiving care from legally-exempt providers in New York City and if program funds were spent for their intended purposes. Auditors found that improvements were needed in the oversight that was provided by the three agencies, as 94 percent of the random sample of 50 providers had one or more issues of noncompliance with health and safety requirements, auditors could not confirm that child care services were actually being provided by 14 of the 50 providers, and two of the providers were registered on the New York State Sex Offender Registry. Auditors recommended that certain improvements be made, and when they followed up on these matters with agency officials, auditors found that progress had been made in implementing the audit recommendations.

Department of Health, Medicaid Payments for Human Immunodeficiency Virus (HIV) Drug Resistance Testing (Follow-Up Report) (2009-F-39)
Human Immunodeficiency Virus (HIV) drug resistance testing is used to establish more effective treatment plans for HIV infected patients who become resistant to medications used to treat the virus. In New York State’s Medicaid program, such testing is reimbursable on a fee-for-service basis up to a maximum of three tests per recipient per year. However, in audit 2007-S-13, during a five-year period, auditors found that this maximum testing threshold was exceeded for a number of Medicaid recipients, and as a result, about $1.27 million in Medicaid overpayments were made. Auditors recommended that the overpayments be recovered and Medicaid claims processing controls be improved to prevent future overpayments. When auditors followed up with DOH officials, they found that little progress had been made implementing the audit recommendations.

Department of Health, Potential Overpayments of Medicaid Provider Claims for Human Immunodeficiency Virus (HIV) Primary Care Services (Follow-Up Report) (2009-F-40)
Medicaid provides an annual evaluation, periodic testing and monitoring services (primary care services) to recipients with the Human Immunodeficiency Virus (HIV). These services are subject to certain frequency limits. In audit 2008-S-5, auditors examined the Medicaid claims submitted by clinics over a three-year period for HIV primary care services and identified a number of instances in which these frequency limits appeared to have been exceeded. For example, in 2006, a clinic billed Medicaid for 12 annual evaluations for the same recipient. Auditors identified a total of about $2.4 million in potential overpayments to 174 such clinics. Auditors recommended DOH investigate the potential overpayments, recover all actual overpayments, and develop controls to prevent such future overpayments. When auditors followed up on this matter, they found DOH had made some progress implementing the audit recommendations.

Department of Civil Service, New York State Health Insurance Program: Overpayments for Services at the Capital Region Ambulatory Surgery Center (Follow-Up Report) (2010-F-6)
In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for active and retired State, local government and school district employees and their dependents. The primary such program is the Empire Plan, which provides services costing more than $5 billion a year.

If an Empire Plan member is treated by a medical service provider that does not participate in the Empire Plan, the Empire Plan will not reimburse the provider for its full charges. Rather, it will only reimburse a portion of these charges (generally 80 percent), and the member will have to pay the balance. However, some non-participating providers routinely waive Empire Plan members’ out-of-pocket expenses. Such a practice may constitute billing fraud, as the Empire Plan is reimbursing 80 percent of what it understands to be the provider’s actual charges.

In audit 2007-S-72, auditors examined the billing practices of a particular non-participating provider (the Capital Region Ambulatory Surgery Center in Albany). We found that the center was routinely waiving Empire Plan members’ out-of-pocket expenses, and as a result, was inappropriately inflating its bills to the Empire Plan. Auditors recommended that the Empire Plan recover the inflated portion of these bills, an amount estimated to be about $2.4 million for the six-year audit period. In addition, auditors referred the provider to Civil Service for appropriate follow-up action. When auditors followed up on these matters, they found that our recommendations had been implemented and the center had become a participating provider. Auditors estimated that, as a result of this change, the Empire Plan was saving nearly $1.5 million annually on its reimbursements to the Center.

Department of Civil Service, New York State Health Insurance Program: Overpayments for Services at the Digestive Health Center of Huntington (Follow-Up Report) (2010-F-7)
In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for active and retired State, local government and school district employees and their dependents. The primary such program is the Empire Plan, which provides services costing more than $5 billion a year.

If an Empire Plan member is treated by a medical service provider that does not participate in the Empire Plan, the Empire Plan will not reimburse the provider for its full charges. Rather, it will only reimburse a portion of these charges (generally 80 percent), and the member will have to pay the balance. However, some non-participating providers routinely waive Empire Plan members’ out-of-pocket expenses. Such a practice may constitute billing fraud, as the Empire Plan is reimbursing 80 percent of what it understands to be the provider’s actual charges.

In audit 2008-S-87, auditors examined the billing practices of a particular non-participating provider (the Digestive Health Center of Huntington, a gastroenterological surgical facility). Auditors found that the center was routinely waiving Empire Plan members’ out-of-pocket expenses, and as a result, was inappropriately inflating its bills to the Empire Plan. Auditors recommended that the Empire Plan recover the inflated portion of these bills, an amount estimated to be about $1.5 million for the six-year audit period. In addition, auditors referred the provider to Civil Service for appropriate follow-up action. When auditors followed up on these matters, they found that the recommendations had been implemented and the center had become a participating provider. Auditors estimated that, as a result of this change, the Empire Plan was saving nearly $700,000 annually on its reimbursements to the center.

Department of Civil Service, New York State Health Insurance Program: Overpayments for Services at the Day-Op Center of North Nassau (Follow-Up Report) (2010-F-8)
In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for active and retired State, local government and school district employees and their dependents. The primary such program is the Empire Plan, which provides services costing more than $5 billion a year.

If an Empire Plan member is treated by a medical service provider that does not participate in the Empire Plan, the Empire Plan will not reimburse the provider for its full charges. Rather, it will only reimburse a portion of these charges (generally 80 percent), and the member will have to pay the balance. However, some non-participating providers routinely waive Empire Plan members’ out-of-pocket expenses. Such a practice may constitute billing fraud, as the Empire Plan is reimbursing 80 percent of what it understands to be the provider’s actual charges.

In audit 2007-S-120, auditors examined the billing practices of a particular non-participating provider (the Day-Op Center of North Nassau, a gastroenterological surgical facility in Great Neck). Auditors found that the center was routinely waiving Empire Plan members’ out-of-pocket expenses, and as a result, was inappropriately inflating its bills to the Empire Plan. Auditors recommended that the Empire Plan recover the inflated portion of these bills, an amount estimated to be almost $1.5 million for the six-year audit period. In addition, we referred the provider to Civil Service for appropriate follow-up action. When auditors followed up on these matters, they found that the recommendations had been implemented and the center had become a participating provider. Auditors estimated that, as a result of this change, the Empire Plan was saving more than $360,000 annually on its reimbursements to the center.

Department of Civil Service, New York State Health Insurance Program: Overpayments for Services at the Day-Op Center of Long Island (Follow-Up Report) (2010-F-9)
In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for active and retired State, local government and school district employees and their dependents. The primary such program is the Empire Plan, which provides services costing more than $5 billion a year.

If an Empire Plan member is treated by a medical service provider that does not participate in the Empire Plan, the Empire Plan will not reimburse the provider for its full charges. Rather, it will only reimburse a portion of these charges (generally 80 percent), and the member will have to pay the balance. However, some non-participating providers routinely waive Empire Plan members’ out-of-pocket expenses. Such a practice may constitute billing fraud, as the Empire Plan is reimbursing 80 percent of what it understands to be the provider’s actual charges.

In audit 2007-S-86, auditors examined the billing practices of a particular non-participating provider (the Day-Op Center of Long Island, a surgical facility in Mineola). Auditors found that the center was routinely waiving Empire Plan members’ out-of-pocket expenses, and as a result, was inappropriately inflating its bills to the Empire Plan. Auditors recommended that the Empire Plan recover the inflated portion of these bills, an amount estimated to be about $1.4 million for the six-year audit period. In addition, we referred the provider to Civil Service for appropriate follow-up action. When auditors followed up on these matters, we found that the recommendations had been implemented and the center had become a participating provider. Auditors estimated that, as a result of this change, the Empire Plan was saving nearly $2.1 million annually on its reimbursements to the center.

Department of Civil Service, New York State Health Insurance Program: Overpayments for Services at the Endoscopy Center of Long Island (Follow-Up Report) (2010-F-10)
In the New York State Health Insurance Program, the Department of Civil Service administers health insurance programs for active and retired State, local government and school district employees and their dependents. The primary such program is the Empire Plan, which provides services costing more than $5 billion a year.

If an Empire Plan member is treated by a medical service provider that does not participate in the Empire Plan, the Empire Plan will not reimburse the provider for its full charges. Rather, it will only reimburse a portion of these charges (generally 80 percent), and the member will have to pay the balance. However, some non-participating providers routinely waive Empire Plan members’ out-of-pocket expenses. Such a practice may constitute billing fraud, as the Empire Plan is reimbursing 80 percent of what it understands to be the provider’s actual charges.

In audit 2007-S-73, auditors examined the billing practices of a particular non-participating provider (the Endoscopy Center of Long Island). Auditors found that the center was routinely waiving Empire Plan members’ out-of-pocket expenses, and as a result, was inappropriately inflating its bills to the Empire Plan. Auditors recommended that the Empire Plan recover the inflated portion of these bills, an amount estimated to be about $2.7 million for the six-year audit period. In addition, auditors referred the provider to the Department of Civil Service for appropriate follow-up action. When auditors followed up on these matters, they found that the recommendations had been implemented and the center had become a participating provider. Auditors estimated that, as a result of this change, the Empire Plan was saving nearly $1 million annually on its reimbursements to the center.

State Government Accountability
The Office of the State Comptroller regularly audits state agencies, public authorities and New York City agencies. Auditors ensure that programs achieve their established goals, funds are used efficiently and assets are adequately protected against fraud, waste and abuse. DiNapoli’s office completes approximately 200 state audits and annually identifies hundreds of millions in savings and fraud each year.

###

Albany Phone: (518) 474-4015 Fax: (518) 473-8940
NYC Phone: (212) 383-1388 Fax: (212) 681-7677
Internet: www.osc.state.ny.us
E-Mail: press@osc.state.ny.us