Erroneous Payments In New York Medicaid Program Just Shy Of $1 Billion

Casey Harper (The Center Square).

An audit released Tuesday by New York State Comptroller Thomas DiNapoli found that the state’s Medicaid program paid $965.1 million in claims over a five-year span to medical professionals not enrolled in the health insurance program.

According to the audit, most errors occurred during the initial three years of the review.

These errors are related to eMedNY which is the claims processing system that the state Department of Health uses to process Medicaid payments to providers. It continued to pay claims for providers who were not licensed to provide Medicaid care.

Auditors found nearly $6 million in claims processed for providers that had been debarred from New York’s Medicaid program.

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DiNapoli stated that the audit revealed the need to address the payment system, particularly since claims were paid to Medicaid providers who weren’t enrolled.

“This not only costs taxpayers but also allows providers who should be excluded, and may be unqualified, to treat patients,” he said. “DOH must improve its efforts to fix the shortcomings with its billing system.”

Nursing homes were the most affected by the majority of these payment mistakes. Auditors found that $628.5million of the total payments was accounted for by nearly 811,000 referrals to and orders for nursing homes. Over 35,000 fraudulent claims from inpatient facilities were valued at $221.6million.

DiNapoli’s report noted that state officials made changes to eMedNY in February 2018 to take care of many erroneous payment issues. However, audits found that auditors had still discovered more than $45 Million in fraudulent payments after the modifications were made.

Medicaid covers a significant amount of New Yorkers’ health-care needs. According to state budget projections, about 7.1 million people were covered in fiscal year 2021, representing more than a third of the state’s population. As state records show, $49.6 Billion of $79.8 Billion in Medicaid funding was provided by Washington.

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DiNapoli’s report calls for the Medicaid program to review the payments made and determine if any recovery efforts should be taken.

The audit recommends, among other things, that providers be educated about OPRA (or ordering, prescribing and referring) services. According to state regulations, physicians and other medical professionals must be registered in the system.

DOH responded that it had reviewed some of the audited claims and determined that they were properly paid. In some instances, DOH said the claims had an actively attending provider – such as a physician, nurse practitioner or specialist – involved. These cases are not subject to referral or order.

However, DiNapoli said none of the claims DOH reviewed were part of the “final scope of the audit” and were excluded from the report. The office provided examples of the claims that it reviewed.

DOH, the Office of Persons with Developmental Disabilities “and other related agencies confirmed that the claim examples we provided did not comply with OPRA requirements,” the audit stated.

This article was Syndicated by permission of The Center Square.