To determine whether improper Medicaid managed care premiums were paid on behalf of recipients with duplicate Client Identification Numbers. The audit covered the period January 1, 2014 to June 30, 2018.
About the Program
The Department of Health (Department) administers New York’s Medicaid program. Many of the State’s Medicaid recipients receive their services through managed care, whereby the Department pays managed care organizations (MCOs) a monthly premium for each enrolled recipient and, in turn, the MCOs pay for services their members require.
Each individual who applies for Medicaid benefits is assigned a Client Identification Number (CIN), a unique identifier. However, Medicaid recipients may have more than one different CIN assigned to them (herein referred to as “duplicate CINs”) during the time they are in receipt of benefits. Consistent with the Department’s guidelines, only one CIN should have active managed care eligibility at a time.
Individuals have several options for enrolling in Medicaid, including through Local Departments of Social Services (Local Districts) and the NY State of Health (NYSOH, the State’s online health plan marketplace). Local Districts use the State’s Welfare Management System (WMS) to process applicant data through both a downstate WMS system for New York City area recipients and an upstate WMS system for recipients in the rest of the State. The NYSOH system processes its applicants’ data.
Regardless of the system from which an individual’s eligibility and enrollment information originates, it is transmitted to the Department’s eMedNY claims processing system. The eMedNY system relies on the information sent by WMS and NYSOH to update eligibility and enrollment data necessary to make appropriate claim payments. When an individual is assigned duplicate CINs, each with its own record of eligibility and managed care enrollment within eMedNY, Medicaid is at risk of making improper concurrent monthly premium payments for each CIN.
- Medicaid made over $102.1 million in improper managed care premium payments on behalf of recipients with duplicate CINs. According to officials we spoke to at the Local Districts, incorrect/missing recipient demographic information and limited access to the multiple eligibility systems during application lead to improper duplicate CINs.
- The Department, Local Districts, MCOs, and the State Office of the Medicaid Inspector General all have processes to identify and resolve duplicate CINs; however, their systems are not fully integrated. There is no central tracking database for duplicate CINs, further limiting the coordination of efforts among these entities.
- The Department recently allocated additional resources to duplicate CIN research and resolution and created a unit for this purpose. However, during our audit period, this unit was primarily responsible for researching potential duplicates involving at least one CIN created by NYSOH, not cases that only involved non-NYSOH-created duplicate CINs. Further, we found this unit did not consider the active eligibility status of the potential duplicate CINs or the cost of associated managed care premiums when prioritizing cases for review.
- Review the $102.1 million in improper premium payments we identified and make recoveries, as appropriate.
- Ensure Local Districts make timely and accurate updates to demographic information on all Medicaid cases (at the time when caseworkers receive such information) to allow proper CIN assignment for new applications and efficient reconciliation of existing duplicates.
- Evaluate the feasibility of building a central tracking database of potential duplicate CINs that shows the status of each case and can be shared among all the stakeholders in the duplicate CIN research and resolution process.
- Ensure that the unit dedicated to duplicate CIN research and resolution takes steps to improve efficiency and timeliness, including, but not limited to, expanding the prioritization methodology to include active eligibility status of the potential duplicate CINs and the cost of associated managed care premium payments, and establishing a benchmark for the time it takes to resolve duplicate CINs.
- Evaluate the feasibility of creating a control to prevent confirmed duplicate CINs from being reused in the future.
State Government Accountability Contact Information:
Audit Director: Andrea Inman
Phone: (518) 474-3271; Email: [email protected]
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236