Med­i­caid claims faulted State au­dit

Comptroller’s of­fice sees $10.2 mil­lion in ex­ces­sive or in­ap­pro­pri­ate pay­ments

Albany Times Union - - EMPIRE STATE - By Bethany Bump

An au­dit of the state’s Med­i­caid pro­gram found that cer­tain types of claims were be­ing pro­cessed in­cor­rectly, re­sult­ing in more than $10 mil­lion worth of in­ap­pro­pri­ate or ex­cess pay­ments, the state comptroller’s of­fice an­nounced Thurs­day.

The au­dit cov­ered from April through Septem­ber 2017 and ex­am­ined the state Health De­part­ment’s emedny com­puter sys­tem that pro­cesses Med­i­caid claims sub­mit­ted by health care providers.

Over that six-month pe­riod, providers sub­mit­ted 193 mil­lion claims and were re­im­bursed more than $31 bil­lion. Most of the claims were pro­cessed and re­im­bursed cor­rectly, but $10.2 mil­lion worth of claims were not, the comptroller’s of­fice said, high­light­ing the need for im­prove­ments in pro­cess­ing cer­tain types of claims, in­clud­ing:

■ $3.7 mil­lion worth of claims that were billed with in­cor­rect in­for­ma­tion re­lated to other in­sur­ance that re­cip­i­ents had;

■ $3.1 mil­lion in over­pay­ments for Med­i­caid claims in­volv­ing Medi­care cov­er­age;

■ $1.3 mil­lion in in­cor­rect new­born birth claims;

■ $783,016 in in­ap­pro­pri­ate feefor-ser­vice pay­ments when the re­cip­i­ent had man­aged care;

■ $684,457 in ex­cess claims for the Com­pre­hen­sive Psy­chi­atric Emer­gency Pro­gram;

■ $465,257 in im­proper episodic home health care pay­ments; and

■ $172,052 in other over­pay­ments.

By the end of the au­dit field­work, about $4.5 mil­lion in over­pay­ments were re­cov­ered, the re­port noted, and the Health De­part­ment said it will work with the Of­fice of the Med­i­caid In­spec­tor Gen­eral to re­coup the rest.

“The de­part­ment stands by its ex­tremely high rate of pay­ment ac­cu­racy (99.7 per­cent of pay­ments re­viewed by the au­dit),” de­part­ment spokes­woman Erin Silk said in an email. “As the au­dit points out, mea­sures are cur­rently in place to en­sure that cor­rect pay­ments are made to qual­i­fied providers.”

Au­di­tors also iden­ti­fied 51 health care providers who par­tic­i­pate in the state Med­i­caid pro­gram and were charged with or found guilty of crimes that vi­o­late health care pro­gram laws and reg­u­la­tions. The Health De­part­ment ter­mi­nated 42 of them.

There is some ques­tion of whether $292,681 that was paid to five of them from the time they were charged with a crime un­til they were ter­mi­nated should be paid back. The comptroller’s of­fice has rec­om­mended the de­part­ment make a de­ter­mi­na­tion one way or the other.

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