The Office of the New York State Comptroller (OSC) has issued two audit reports on Medicaid payment activities of the New York State Department of Health (NYSDOH).  OSC found that NYSDOH was still making millions of dollars in improper Medicaid payments.  You can access and read the OSC audit reports below.

Department of Health – Medicaid Claims Processing Activity April 1, 2023 Through September 30, 2023 (2023-S-9)

During the six-month period ended September 30, 2023, the Department of Health’s eMedNY computer system processed over 420 million claims, resulting in payments to providers of more than $47.1 billion.  OSC’s audit of Medicaid claims processing activity identified about $13.5 million in improper Medicaid payments for claims that were not processed in accordance with Medicaid requirements.  The audit also identified 12 providers in the Medicaid program 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.

Department of Health – Medicaid Program – Excessive Premium Payments for Dual-Eligible Recipients Enrolled in Mainstream Managed Care and Health and Recovery Plans (Follow-Up) (2023-F-39)

Many Medicaid recipients are enrolled in Medicare and are referred to as “dual-eligibles.”  Additionally, many Medicaid recipients receive their services through managed care, including Mainstream Managed Care (MMC), which provides comprehensive coverage, and Health and Recovery Plans (HARP), which provide specialized care to recipients age 21 or older with serious mental illness and/or substance use disorders.  Within MMC and HARP is the Integrated Benefits for Dually Eligible Enrollees Program (IB-Dual), which pays lower MMC and HARP premium rates for Medicaid recipients in MMC or HARP who enroll in Medicare and do not need long-term services and support.  A prior audit, issued in October 2022, found over $190.6 million was paid on behalf of dual-eligible recipients who were ineligible for IB-Dual and over $3.5 million was paid on behalf of dual-eligible recipients who appeared eligible for IB-Dual but were not enrolled in a timely manner.  The follow-up found DOH officials made progress with the initial audit’s four recommendations, implementing two and partially implementing two.