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September 30, 2009

DiNapoli: Optometrist Inappropriately
Billing Medicaid

A Staten Island optometrist received almost $240,000 from the New York State Medicaid program for unsupported and inappropriate claims over a five year period, according to an audit of the New York State Department of Health (DOH) released today by State Comptroller Thomas P. DiNapoli.

“The usual standard for eye exams is once every two years,” DiNapoli said. “The doctor billed for eye exams every two months. We can’t allow unscrupulous providers to bilk taxpayers. DOH has to make sure it does everything possible to eliminate Medicaid fraud, waste and abuse. Now more than ever, we have to watch every taxpayer dime.”

Kenneth Horowitz, OD, an optometrist from Staten Island, received approximately $370,000 from Medicaid during the five-year period ended September 30, 2008. From 2003 through 2008, Dr. Horowitz submitted claims for 221 to 777 Medicaid recipients annually. His average Medicaid claim reimbursement was nearly twice the average claim reimbursement for all Medicaid optometrists.

Under federal Medicaid requirements, optometrist services are considered optional services which States may choose to provide. New York includes these services in its Medicaid program at a cost of around $12 million a year.

The usual frequency for optometric eye examinations is once every two years, but DiNapoli’s auditors found Horowitz routinely billed Medicaid for multiple examinations for many of his patients during a 24-month period. One patient received 14 exams. The patients rarely received other eye care services that would indicate vision problems requiring treatment and increased monitoring.

DiNapoli’s auditors also found that Horowitz frequently added other procedures with claims for standard eye examinations. For example, Dr. Horowitz was reimbursed $2,209 by Medicaid for performing 47 different procedures on 20 Medicaid recipients residing at the Staten Island Care Center’s nursing home. For 17 of those patients, Dr. Horowitz billed Medicaid for standard eye examinations as well as extended ophthalmoscopies, more detailed examinations of the eye generally performed when a serious retinal condition exists.

When auditors requested the medical records for a randomly selected sample of 69 claims for the additional procedure, records for 38 of these claims were missing. Of the 31 files auditors were able to review, only one included all of the records required to be kept.

Auditors recommended DOH:

  • Investigate the $239,500 in potential Medicaid overpayments identified during this audit and recover any unsupported or otherwise inappropriate payments.
  • Review Medicaid payments made to Dr. Horowitz subsequent to September 30, 2008 and determine if any were improper; and
  • Formally assess whether Dr. Horowitz should be decertified from the Medicaid program.

Auditors have referred these matters to the Office of the Medicaid Inspector General for further investigation.

DOH officials agreed to take action on DiNapoli's audit recommendations.

Click here for a complete copy of the audit.

About the State Comptroller’s Medicaid Audits
The Office of the State Comptroller conducts regular audits of the state’s $45 billion Medicaid program. In 2009, DiNapoli’s auditors have identified $25.6 million in overpayments and savings. Auditors review Medicaid claims that have been 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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