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Whitestone School for Child Development – Compliance With the Reimbursable Cost Manual
… the ages of three and five years. Whitestone, located in Queens, New York, provides preschool services throughout … 30, 2013, Whitestone reported approximately $2.3 million in reimbursable costs for the programs. Key Findings For the … fiscal years ended June 30, 2013, we identified $154,563 in reported costs that did not comply with Manual …
https://www.osc.ny.gov/state-agencies/audits/2015/04/07/whitestone-school-child-development-compliance-reimbursable-cost-manualUnited HealthCare – Overpayments for Services Provided by Long Island Spine Specialists
… provided to Empire Plan members. United contracts with in-network participating providers who agree to accept … co-insurance) when they use non-participating providers. In accordance with the Empire Plan’s requirements, when … waives) the member’s out-of-pocket costs, it will result in United making an excessive payment on the claim. Our audit …
https://www.osc.ny.gov/state-agencies/audits/2016/05/05/united-healthcare-overpayments-services-provided-long-island-spine-specialistsMedicaid Program – Managed Care Organizations’ Readiness for the Encounter Intake System
… Intake System (EIS) began accepting encounter transactions from MCOs. (Prior to the EIS, MCOs submitted encounter … to submit encounter transactions to the EIS increased from 10 to 43 (of 52) by November 20, 2015. Key …
https://www.osc.ny.gov/state-agencies/audits/2016/03/29/medicaid-program-managed-care-organizations-readiness-encounter-intake-systemMonitoring of Medicaid Payments for Nursing Home Bed Reserve Days (Follow-Up)
… audit report, Monitoring of Medicaid Payments for Nursing Home Bed Reserve Days (Report 2010-S-21). Background Our … was issued on December 9, 2010, examined whether nursing home claims submitted to Medicaid for hospital bed reserve … days were appropriate, and if not, to what extent nursing home claims exceeded the bed reserve day limits. During the …
https://www.osc.ny.gov/state-agencies/audits/2013/01/10/monitoring-medicaid-payments-nursing-home-bed-reserve-days-followExcessive Medicaid Payments for Services to Recipients Receiving Medicare Benefits (Follow-Up)
… more proactive culture that seeks to ensure that Medicaid is the payer of last resort for services provided to dual …
https://www.osc.ny.gov/state-agencies/audits/2013/04/26/excessive-medicaid-payments-services-recipients-receiving-medicare-benefits-followUnited HealthCare – Overpayments for Services Provided by Long Island Laparoscopic Surgery
… provided to Empire Plan members. United contracts with in-network participating providers who agree to accept … co-insurance) when they use non-participating providers. In accordance with the Empire Plan’s requirements, when … waives) the member’s out-of-pocket costs, it will result in United making an excessive payment on the claim. Our audit …
https://www.osc.ny.gov/state-agencies/audits/2016/05/05/united-healthcare-overpayments-services-provided-long-island-laparoscopic-surgeryAstor Services for Children & Families – Compliance With the Reimbursable Cost Manual
… Background Astor, a not-for-profit organization located in Rhinebeck, New York, provides preschool special education … reported costs must comply with the guidelines specified in the RCM. For the fiscal year ended June 30, 2013, Astor reported a total of $6.4 million in reimbursable costs on its CFR, of which $3.3 million was …
https://www.osc.ny.gov/state-agencies/audits/2015/09/02/astor-services-children-families-compliance-reimbursable-cost-manualImproper Payments for Controlled Substances That Exceed Allowed Dispensing Limits (Follow-Up)
… We recommended that the Department review the improper pharmacy claims we identified and make recoveries. We also … included implementing controls to prevent the payment of pharmacy claims for quantities of controlled substances that …
https://www.osc.ny.gov/state-agencies/audits/2016/09/23/improper-payments-controlled-substances-exceed-allowed-dispensing-limits-followImproper Fee-for-Service Payments for Pharmacy Services Covered by Managed Care (Follow-Up)
… of implementation of the three recommendations included in our initial audit report, Improper Fee-for-Service … Key Finding Department officials have made some progress in addressing the problems we identified in the initial audit report. However, further actions are …
https://www.osc.ny.gov/state-agencies/audits/2016/09/23/improper-fee-service-payments-pharmacy-services-covered-managed-care-followStarting Point Services for Children – Compliance With the Reimbursable Cost Manual
… (SCIS) programs to disabled children between the ages of three and five years. During the 2012-13 school year, … Point served 942 students. The New York City Department of Education (DoE) refers students to Starting Point based on … SED on its annual CFRs. SED reimburses DoE for a portion of its payments to Starting Point based on statutory rates. …
https://www.osc.ny.gov/state-agencies/audits/2015/12/11/starting-point-services-children-compliance-reimbursable-cost-manualUnitedHealthcare – Improper Payments for Medical Services Designated By Modifier Code 59
… members. United’s payments to medical providers are based, in part, on procedure codes billed on claims that indicate … United will not pay for certain procedure codes billed in combination with other procedure codes unless the provider … for claims preparation and submission. Recover the $39,345 in overpayments identified by our audit. As priorities and …
https://www.osc.ny.gov/state-agencies/audits/2015/01/08/unitedhealthcare-improper-payments-medical-services-designated-modifier-code-59Milestone School for Child Development – Compliance With the Reimbursable Cost Manual
… 30, 2013, Milestone reported approximately $3.8 million in reimbursable costs for its SED Programs. Our audit scope … fiscal years ended June 30, 2013, we identified $801,859 in reported costs that did not comply with Manual … be disallowed. These ineligible costs included $285,455 in personal services costs and $516,404 in other than …
https://www.osc.ny.gov/state-agencies/audits/2015/07/17/milestone-school-child-development-compliance-reimbursable-cost-manualAdministration of the Contract With the Center for Urban Community Services
… of the largest such contracts DOHMH awarded was with CUCS. In 2010, DOHMH signed a three-year contract with CUCS valued … to the contract, DOHMH reimburses CUCS on a monthly basis, in an amount equal to claimed program costs less any advance payments and not in excess of the total contract amount. DOHMH requires CUCS, …
https://www.osc.ny.gov/state-agencies/audits/2016/02/16/administration-contract-center-urban-community-servicesMedicaid Overpayments for Inpatient Transfer Claims Among Merged or Consolidated Facilities
… for their services. Generally, when a Medicaid recipient is transferred among different hospitals, two separate … facility. Under these circumstances, when a recipient is transferred from the first hospital to a merged or … Payments for Misclassified Patient Discharges (2009-S-26) Department of Health: Medicaid Claims Processing …
https://www.osc.ny.gov/state-agencies/audits/2015/12/08/medicaid-overpayments-inpatient-transfer-claims-among-merged-or-consolidated-facilitiesMedicaid Program – Overpayments of Hospitals' Claims for Lengthy Acute Care Admissions
… for inpatient services, hospitals must indicate a patient's level of care on a claim to ensure accurate processing and … Although the hospital provided acute care on the first day of the admission, the patient actually received less … million per year. Given the relatively high incidence (32 percent) of overpayments from the sample that was …
https://www.osc.ny.gov/state-agencies/audits/2013/07/25/medicaid-program-overpayments-hospitals-claims-lengthy-acute-care-admissionsAll Services for Kids, Inc. – Compliance With the Reimbursable Cost Manual
… ended June 30, 2010. Background All Services, located in Fresh Meadows, New York, provided special education … based on the financial information All Services presented in its annual CFRs. According to its CFRs for the two fiscal … 30, 2010, All Services claimed approximately $1.3 million in reimbursable expenses. All Services' CFR for the fiscal …
https://www.osc.ny.gov/state-agencies/audits/2014/02/25/all-services-kids-inc-compliance-reimbursable-cost-manualMedicaid Program – Improper Payments of Medicare Buy-in Premiums for Ineligible Recipients
… Medicare premium payments on behalf of recipients enrolled in the Medicare buy-in program. The audit covered Medicaid payments for individuals enrolled in the Medicare buy-in program for the period from January 1, … Medicare premium payments on behalf of recipients enrolled in the Medicare buyin program …
https://www.osc.ny.gov/state-agencies/audits/2021/11/29/medicaid-program-improper-payments-medicare-buy-premiums-ineligible-recipientsOverpayments for Therapy Services and Prescription Drugs Covered by Medicare (Follow-Up)
… audit report, Overpayments for Therapy Services and Prescription Drugs Covered by Medicare (Report 2016-S-73 ). About the Program The New York … occupational, and speech therapy services as well as prescription drugs. When these services are rendered to … initial audit report Overpayments for Therapy Services and Prescription Drugs Covered by Medicare Report 2016S73 …
https://www.osc.ny.gov/state-agencies/audits/2021/11/29/overpayments-therapy-services-and-prescription-drugs-covered-medicare-followEmpire BlueCross – Improper Payments for Intraocular Lens Claims Billed by Hospitals
… not covered by fee schedules. Intraocular lenses are used in the treatment of cataracts – the clouding of the lens in the eye – which cause vision problems. A cataract is … not be paid. When hospitals send claims for reimbursement, in addition to general service codes, they typically include …
https://www.osc.ny.gov/state-agencies/audits/2019/12/20/empire-bluecross-improper-payments-intraocular-lens-claims-billed-hospitalsManaged Care Premium Payments for Recipients With Comprehensive Third-Party Insurance (Follow-Up)
… in) provides comprehensive medical services that range from hospital care and physician services to dental and … (Department) policy is to exclude Medicaid recipients from enrollment in mainstream managed care when they also … with comprehensive TPHI and promptly disenrolling them from managed care. We issued our initial audit report on June …
https://www.osc.ny.gov/state-agencies/audits/2020/01/17/managed-care-premium-payments-recipients-comprehensive-third-party-insurance-follow