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September 8, 2008

DiNapoli: Audit Finds $1.27 Million in Medicaid Billing Problems

The state Department of Health (DOH) said it will strengthen oversight over Medicaid payments and evaluate the appropriate number of HIV drug resistance tests allowed annually for Medicaid patients after an audit found that medical providers billed the state for significantly more tests than is permitted under current guidelines.

“There’s a Medicaid claims processing system that’s supposed to red flag questionable bills,” DiNapoli said. “Here’s yet another failure of that system. The state Department of Health is evaluating whether the current guidelines meet the needs of patients. That’s good. What’s not so good is that questionable charges keep slipping through.

“We have a stack of audits showing providers who have exploited weaknesses in the claims processing system in order to get paid more. Patients should get the care they need, and taxpayers should only pay for what’s necessary. Every dime counts, and every dime spent wrong means less money for prevention and care.”

While Medicaid recipients are allowed three tests per year under law, in an analysis of Medicaid payments during the five years ended December 31, 2007, auditors found one provider billed for twelve tests for one patient in a single year. In total, auditors identified $1.27 million that was paid to medical providers who billed for more than the allowed number of tests.

Auditors found that controls in eMedNY, the claims payment and information reporting system used by DOH to process claims, were not properly set up, enabling medical providers to bill for these extra tests.

DOH agreed with the audit findings and indicated that it would implement the necessary controls in eMedNY to prevent future overpayments and evaluate the current standard of care for testing. The findings of the audit were referred to the state Office of the Medicaid Inspector General for further review.

Click here to for a copy of the audit.

In July, DiNapoli released a Medicaid audit that found similar problems with eMedNY. A Brooklyn dentist was able to bill Medicaid for filling and then pulling all 32 teeth for multiple patients. DiNapoli’s auditors determined DOH had not established controls in eMedNY to detect excessive or improbable procedures.

About the State Comptroller’s Medicaid Audits
The Office of the State Comptroller conducts regular audits of the state’s $47 billion Medicaid program. Auditors review Medicaid claims submitted by service providers and identify billing patterns and other circumstances that warrant an examination to determine whether claims are valid and appropriate.



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