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Madrid-Waddington Central School District - Claims Audit Process (2019M-1)
… Determine whether claims were adequately documented, were for appropriate purposes and were properly audited and … claims auditor did not audit two claims totaling $251,601 for health insurance and Medicare reimbursement. In addition, … $5,700. Key Recommendations Ensure that all claims for health insurance, Medicare reimbursements and scholarship …
https://www.osc.ny.gov/local-government/audits/school-district/2019/03/08/madrid-waddington-central-school-district-claims-audit-process-2019m-1Improper Payments of Medicare Buy-In Premiums for Ineligible Recipients (2020-S-35) 180-Day Response
To determine if Medicaid made improper Medicare premium payments on behalf of recipients enrolled in the Medicare buy-in program.
https://www.osc.ny.gov/files/state-agencies/audits/pdf/sga-2022-20s35-response.pdfMedicaid Program – Excessive Medicaid Payments to Federally Qualified Health Centers for Group Therapy Services
… To determine if Medicaid reimbursement rates for group therapy services provided by Federally Qualified Health … Qualified Health Centers (FQHCs) to provide group therapy services, including group therapy provided by clinical social workers, to Medicaid … To determine if Medicaid reimbursement rates for group therapy services provided by Federally Qualified Health …
https://www.osc.ny.gov/state-agencies/audits/2014/11/18/medicaid-program-excessive-medicaid-payments-federally-qualified-health-centers-groupMedicaid Program – Mainstream Managed Care Organizations: Administrative Costs Used in Premium Rate Setting
… disadvantaged and/or have special health care needs. For the State fiscal year ended March 31, 2015, New York’s … managed care, Medicaid pays MCOs a monthly premium payment for each enrolled Medicaid recipient and the MCOs arrange for the provision of services their members require. The …
https://www.osc.ny.gov/state-agencies/audits/2016/10/13/medicaid-program-mainstream-managed-care-organizations-administrative-costs-used-premiumMedicaid Program – Cost Saving Opportunities on Payments of Medicare Part C Claims
… Medicaid and Medicare. Medicare is the primary payer for medical services provided to these dual-eligible recipients. … by offering different health care plans (known as Medicare Advantage Plans) and processing and paying claims for … or coinsurance) was no more than the typical Medicaid fee, it could have saved over $419 million from July 1, 2016 to …
https://www.osc.ny.gov/state-agencies/audits/2021/09/21/medicaid-program-cost-saving-opportunities-payments-medicare-part-c-claimsMedicaid Program – Improper Payments for Ancillary Services Provided During Hospital Inpatient Admissions
… services provided in the home, medical offices, clinics, and other freestanding sites. They can be classified into three general categories: diagnostic, therapeutic, and custodial. For example, laboratory, physical therapy, and … for review. Medicaid reimbursement rates for inpatient hospital claims include the costs of most medical care …
https://www.osc.ny.gov/state-agencies/audits/2014/04/03/medicaid-program-improper-payments-ancillary-services-provided-during-hospital-inpatientNew York State Comptroller Thomas P. DiNapoli Statement on Federal Tax Reform
… of coverage for many New Yorkers. "The legislation will drive up the cost of borrowing for state and local …
https://www.osc.ny.gov/press/releases/2017/12/new-york-state-comptroller-thomas-p-dinapoli-statement-federal-tax-reform-0DiNapoli: Medicaid Audits Find Nearly $800 Million in Savings and Revenue
… program. The audits identified approximately $790 million in savings from eliminating unnecessary payments and … budget gap of $6 billion for the coming fiscal year, in part because of higher Medicaid spending,” DiNapoli said. … on the Medicaid program, uncovering billions of dollars in waste, fraud and abuse. Our role is to help lower Medicaid …
https://www.osc.ny.gov/press/releases/2020/01/dinapoli-medicaid-audits-find-nearly-800-million-savings-and-revenueMedicaid Program – Medicaid Payments Made Pursuant to Medicare Part C
… determine if Medicaid made excessive payments for Medicare Part C cost-sharing liabilities. The audit covered the period … "dual-eligibles." In 1997, Congress established Medicare Part C, also known as Medicare managed care or Medicare Advantage. Under Medicare Part C, private managed care companies administer Medicare …
https://www.osc.ny.gov/state-agencies/audits/2014/05/09/medicaid-program-medicaid-payments-made-pursuant-medicare-part-cChildren's Development Group, PLLC – Compliance With the Reimbursable Cost Manual
… submitted by Children’s Development Group, PLLC (CDG) on its Consolidated Fiscal Report (CFR) were allowable, properly … information, including costs, that CDG reports to SED on its annual CFR. To be eligible for reimbursement, reported … 30, 2016, CDG reported $427,599 in reimbursable costs for its Preschool Integrated Special Class – over 2.5 hours per …
https://www.osc.ny.gov/state-agencies/audits/2019/12/11/childrens-development-group-pllc-compliance-reimbursable-cost-manualMedicaid Program – Medicaid Claims Processing Activity October 1, 2017 Through March 31, 2018
… was paid for recipients enrolled in managed care; $1.6 million was paid for newborn birth claims; $1.4 million was … policies. By the end of the audit fieldwork, about $6.7 million of the improper payments had been recovered. …
https://www.osc.ny.gov/state-agencies/audits/2019/02/05/medicaid-program-medicaid-claims-processing-activity-october-1-2017-through-march-31-2018DiNapoli: Audit Finds $6.8 Million in Medicaid Overpayments
… $3,521,562 in overpayments for 14,983 fee-for-service clinic claims that were inappropriate. The claims were … not have been paid. A data entry error in eMedNY allowed clinic services for enrollees of this plan to be processed as … weights; $389,813 in improper payments for inpatient, clinic, durable medical equipment, transportation, and eye …
https://www.osc.ny.gov/press/releases/2016/11/dinapoli-audit-finds-68-million-medicaid-overpaymentsMedicaid Program – Improper Fee-for-Service Payments for Pharmacy Services Covered by Managed Care
… premium for every Medicaid recipient enrolled in the MCO, and the MCO arranges for the provision of services its members … paid approximately $46.5 billion in premiums to 92 MCO plans. Key Findings Medicaid inappropriately paid 29,289 …
https://www.osc.ny.gov/state-agencies/audits/2015/01/05/medicaid-program-improper-fee-service-payments-pharmacy-services-covered-managed-careMedicaid Program – Improper Payments for Certain Third-Party Cost-Sharing Claims
… made overpayments to providers who reported claims with a PR 45 cost-sharing amount. The audit covered the period from … unpaid portion of the claim balance. Group codes include PR (patient responsibility) and CO (contractual obligation). … claims processing and payment system. Claims with a CARC PR 45 are currently configured to pay in eMedNY, while claims …
https://www.osc.ny.gov/state-agencies/audits/2025/11/05/medicaid-program-improper-payments-certain-third-party-cost-sharing-claimsOverpayments of Certain Medicare Crossover Claims
… of Health (Department) implemented the Medicare/ Medicaid claim crossover system. Under the system, providers submit … because eMedNY incorrectly interpreted certain crossover claim adjustment codes; and did not properly apply Medicaid …
https://www.osc.ny.gov/state-agencies/audits/2013/01/10/overpayments-certain-medicare-crossover-claimsState Health Department Unnecessarily Paid over $1 Billion for Patients Covered by Private Insurance
… The state Department of Health (DOH) paid $1.28 billion in unnecessary Medicaid managed care premiums over a nearly six-year period for enrollees who already had private insurance, according to an audit released today by State … The state Department of Health DOH paid $128 billion in unnecessary Medicaid managed …
https://www.osc.ny.gov/press/releases/2018/06/state-health-department-unnecessarily-paid-over-1-billion-patients-covered-private-insuranceDiNapoli: Audit Finds More Than $16 Million in Medicaid Cost Savings
… an additional $13.6 million in total net payments for 781 recipients eligible for Medicare identified in the …
https://www.osc.ny.gov/press/releases/2017/07/dinapoli-audit-finds-more-16-million-medicaid-cost-savingsDiNapoli: Audits Find More Than $1 Million of Waste in New York's Medicaid Program
… money spent on this important program is not being wasted and is being used for necessary and appropriate treatments. … costs totaled about $50.5 billion. DOH generally uses two methods to pay Medicaid providers: the fee-for-service … including pharmacy benefits, for Medicaid recipients. In one audit, DiNapoli’s auditors found the inappropriate …
https://www.osc.ny.gov/press/releases/2015/01/dinapoli-audits-find-more-1-million-waste-new-yorks-medicaid-programDiNapoli: New York May Be Paying Medicaid Premiums for People Living Out-of-State
… of Health (NYSOH) or through local departments of social services (Local Districts). Most of the state’s Medicaid … those services. In exchange, DOH pays the plans a monthly premium for each enrolled member. Generally speaking, if a … in October 2019. The audit identified $1.5 billion in premium payments that were made from 2017 to 2019 for …
https://www.osc.ny.gov/press/releases/2025/09/dinapoli-new-york-may-be-paying-medicaid-premiums-people-living-out-stateImproper Payments of Medicare Buy-in Premiums for Ineligible Recipients (Follow-Up) (2022-F-37)
To assess the extent of implementation of the five recommendations included in our initial audit report, Improper Payments of Medicare Buy-In Premiums for Ineligible Recipients (Report 2020-S-35).
https://www.osc.ny.gov/files/state-agencies/audits/pdf/sga-2023-22f37.pdf