By Forum Staff
The State Department of Health’s eMedNY computer system improperly paid $16.2 million in Medicaid claims during a six-month period that started in October 2023, according to an audit released on Thursday by State Comptroller Tom DiNapoli.
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 ended March 31, 2024, eMedNY processed over 370 million claims, resulting in payments to providers of nearly $49.6 billion. The claims are processed and paid in weekly cycles, which averaged about 14 million claims and $1.9 billion in payments to providers.
The bulk of the improper payments, $11.8 million, went to pay 27,480 Medicaid managed care premiums for recipients who were ineligible for managed care coverage because they had comprehensive third-party insurance and should’ve been enrolled in Medicaid fee-for-service instead. As a result of the audit, more than $2.8 million in improper payments have already been recovered.
The audit determined eMedNY reasonably ensured Medicaid claims were submitted by approved providers, were processed in accordance with requirements, and resulted in correct payments to providers. However, DiNapoli’s office also identified the need for improvements in the processing of certain types of claims. The audit identified millions of dollars in improper payments, as follows:
- $2 million was paid for fee-for-service inpatient claims that should have been paid by managed care.
- $1.3 million was paid for newborn birth and maternity claims that contained inaccurate information, such as low newborn birth weights that increased reimbursements.
- $964,333 was paid for inpatient, pharmacy, referred ambulatory, and clinic claims that did not comply with Medicaid policies.
- $126,786 was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer.
- $35,441 was paid for managed care premiums on behalf of incarcerated recipients whose managed care coverage should have been suspended.
The audit also identified 10 Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs. In response to the findings, DOH removed nine of the providers from the Medicaid program and had not yet resolved the program status of the remaining provider.
The audit made 10 recommendations, including informing hospitals to accurately report to and bill Medicaid, along with identifying where financial recoveries should be made.
The Department of Health’s response included highlighting its actions regarding the audit’s findings as well as noting the Office of the Medicaid Inspector General’s investigative and audit process to ensure Medicaid providers and recipients are complying with the laws and regulations.
“My office pays close attention to Medicaid because it’s critical for so many New Yorkers and a big driver of state spending,” DiNapoli said. “Errors can be costly. My office’s latest audit found areas where the Department of Health can do better and avoid improper and wasteful spending of taxpayer dollars. By acting swiftly on the audit’s recommendations DOH has already recovered millions of dollars.”
