Objective

To determine whether the Department of Health’s eMedNY system reasonably ensured that Medicaid claims were submitted by approved providers, were processed in accordance with Medicaid requirements, and resulted in correct payments to providers. The audit covered the period from April 2023 through September 2023, and certain claims going back to January 2022.

About the Program

The Department of Health (DOH) administers the State’s Medicaid program. DOH’s eMedNY computer system processes claims submitted by providers for services rendered to Medicaid-eligible recipients and generates payments to reimburse the providers for their claims. During the 6-month period ending September 30, 2023, eMedNY processed over 420 million claims, resulting in payments to providers of more than $47.1 billion. The claims are processed and paid in weekly cycles, which averaged about 16 million claims and $1.8 billion in payments to providers.

Key Findings

The audit identified about $13.5 million in improper Medicaid payments, as follows:

• $9.3 million was paid for managed care premiums on behalf of Medicaid recipients who had other concurrent comprehensive third-party health insurance;
• $2.4 million was paid for fee-for-service inpatient claims that should have been paid by managed care;
• $985,786 was paid for newborn birth and maternity claims that contained inaccurate information, such as the newborn’s birth weight;
• $582,101 was paid for inpatient, clinic, referred ambulatory, lab, and practitioner claims that did not comply with Medicaid policies;
• $167,098 was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer; and
• $77,703 was paid for managed care premiums on behalf of incarcerated recipients whose managed care coverage should have been suspended.

As a result of the audit, more than $2.8 million of the improper payments was recovered. We also identified 12 Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs or who were otherwise barred from participating in the Medicaid program.

Key Recommendations

We made eight recommendations to DOH to recover the remaining inappropriate Medicaid payments and improve claims processing controls.