Objective

To determine the extent of implementation of the five recommendations included in our initial audit report, Medicaid Overpayments for Medicare Part B Services Billed Directly to eMedNY (Report 2017-S-36).

About the Program

The Department of Health (Department) administers the State’s Medicaid Program. Many Medicaid recipients are also enrolled in Medicare Part B (Part B), which provides supplemental insurance coverage for outpatient medical services, physician services, and medical supplies. As the secondary payer, Medicaid generally pays the Part B cost-sharing amounts (e.g., deductibles and coinsurance) for these dual-eligible individuals.

Our initial audit report, issued on December 11, 2018, examined whether Medicaid made improper payments to providers who submitted Part B cost-sharing claims directly to eMedNY, the Medicaid claims processing and payment system. The audit covered the period June 1, 2012 through May 31, 2017 and identified up to $8.7 million in improper payments for Part B deductibles and coinsurance. We determined many of the overpayments occurred because eMedNY controls were not in place to prevent the payment of coinsurance for non-covered services as well as excessive annual deductibles. We recommended the Department review the payments identified by the audit and recover overpayments, as appropriate; formally advise providers to report accurate claim information when billing Medicaid for Part B deductibles and coinsurance on direct-bill claims; and enhance controls to prevent overpayments for Part B deductibles and coinsurance on direct bill claims.

Key Finding

Department officials made some progress in addressing the problems identified in the initial audit. For instance, the Department implemented a new claim processing control to prevent payment of excessive Part B deductibles and enhanced an existing claim processing control to prevent overpayment of Part B coinsurance. However, the Office of the Medicaid Inspector General only recovered about $325,000 of the overpayments identified. Of the initial report’s five audit recommendations, one was implemented and four were partially implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.