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Payments for Fraudulent and Improper Claims Submitted by Davis Ethical Pharmacy (Follow-Up)
… of implementation of the three recommendations included in our initial audit report, Payments for Fraudulent and … 10, 2015, William Davis pleaded guilty to Grand Larceny in the Second Degree in Nassau County District Court. He was sentenced on February … the extent of implementation of 3 recommendations included in our initial audit report Payments for Fraudulent and …
https://www.osc.ny.gov/state-agencies/audits/2016/02/18/payments-fraudulent-and-improper-claims-submitted-davis-ethical-pharmacy-followMedicaid Program – Improper Fee-for-Service Payments for Pharmacy Services Covered by Managed Care
… disadvantaged and/or have special health care needs. In general, the Medicaid program pays medical providers … a monthly premium for every Medicaid recipient enrolled in the MCO, and the MCO arranges for the provision of … was no longer appropriate for recipients enrolled in managed care. As of December 2013, approximately 4 million …
https://www.osc.ny.gov/state-agencies/audits/2015/01/05/medicaid-program-improper-fee-service-payments-pharmacy-services-covered-managed-careEducators for Children, Youth and Families, Inc. – Use of Contract Funds (Follow-Up)
… of implementation of the three recommendations included in our initial audit report, Educators for Children, Youth … claims amounting to $1.8 million, out of $3.2 million in contract payments, to determine if the claims were … fraudulent transactions to an inactive Board of Directors. In addition, we found no evidence that there were any …
https://www.osc.ny.gov/state-agencies/audits/2013/08/13/educators-children-youth-and-families-inc-use-contract-funds-followMedicaid Program – Improper Payments for Ancillary Services Provided During Hospital Inpatient Admissions
… system processes Medicaid claims for ancillary services in accordance with Medicaid reimbursement policies. The audit … Ancillary services refer to health care services provided in the home, medical offices, clinics, and other freestanding … controls within eMedNY designed to pay Medicaid claims in accordance with the Department's Medicaid reimbursement …
https://www.osc.ny.gov/state-agencies/audits/2014/04/03/medicaid-program-improper-payments-ancillary-services-provided-during-hospital-inpatientMedicaid Program – Medicaid Payments for Pharmacy Claims: Joia Pharmacy and a Related Prescriber
… a related prescriber (herein referred to as “the Doctor”) in compliance with applicable Medicaid laws and … oversight authorities of some of the matters addressed in this report. Subsequent to that review, we provided the … pharmacists who work at pharmacies that are enrolled in the Medicaid program. During the audit period, Joia, doing …
https://www.osc.ny.gov/state-agencies/audits/2017/06/27/medicaid-program-medicaid-payments-pharmacy-claims-joia-pharmacy-and-related-prescriberOversight of Hotels and Motels Used for Homeless and Mixed-Use Temporary Residency
… report, of the more than 86,000 homeless people in New York State, almost 13,000 (15 percent) are located in areas outside of New York City (NYC). Counties throughout … house a substantial portion of their homeless populations. In fact, for many rural counties, hotels and motels are the …
https://www.osc.ny.gov/state-agencies/audits/2017/06/27/oversight-hotels-and-motels-used-homeless-and-mixed-use-temporary-residencyMedicaid Program – Reducing Medicaid Costs for Recipients With End Stage Renal Disease
… renal disease who were eligible for, but not enrolled in, Medicare. The audit covered the period January 1, 2010 … End stage renal disease (ESRD) is a medical condition in which a person has permanent kidney failure and requires … When Medicaid recipients with ESRD are also enrolled in Medicare, Medicare becomes the primary insurer (payer) and …
https://www.osc.ny.gov/state-agencies/audits/2017/03/01/medicaid-program-reducing-medicaid-costs-recipients-end-stage-renal-diseaseSt. Mary’s Hospital for Children, Inc. – Compliance With the Reimbursable Cost Manual
… Objective To determine whether the costs reported by St. Mary’s Hospital for Children, Inc. (St. Mary’s) on its Consolidated Fiscal Reports (CFRs) were … To determine whether the costs reported by St Marys Hospital for Children Inc on its Consolidated Fiscal Reports …
https://www.osc.ny.gov/state-agencies/audits/2022/11/09/st-marys-hospital-children-inc-compliance-reimbursable-cost-manualImproper Fee-for-Service Payments for Services Covered by Managed Long-Term Care Plans (Follow-Up)
… included in our initial audit report, Improper Fee-for-Service Payments for Services Covered by Managed Long-Term Care Plans (Report … that identify the services that plans must cover and pay for (benefit packages) in exchange for monthly premium … our initial audit report Improper FeeforService Payments for Services Covered by Managed LongTerm Care Plans Report …
https://www.osc.ny.gov/state-agencies/audits/2021/08/31/improper-fee-service-payments-services-covered-managed-long-term-care-plans-followQuality Services for the Autism Community – Compliance With the Reimbursable Cost Manual
… QSAC’s administrative office for all programs is located in Manhattan. QSAC was established in 1978 and is approved by SED to provide Preschool Special … years of age. Both the SC and SEIT programs are located in Douglaston, Queens. For the fiscal year ended June 30, …
https://www.osc.ny.gov/state-agencies/audits/2019/12/31/quality-services-autism-community-compliance-reimbursable-cost-manualMedicaid Program – Improper Fee-for-Service Payments for Services Covered by Long-Term Care Plans
… Many of the State’s Medicaid recipients are enrolled in MLTC plans. MLTC plans provide long-term care services, … pays MLTC plans monthly managed care premiums and, in return, MLTC plans pay for all MLTC covered services. The … services covered by MLTC plans. Individuals are enrolled in MLTC through either Local Departments of Social Services …
https://www.osc.ny.gov/state-agencies/audits/2020/01/17/medicaid-program-improper-fee-service-payments-services-covered-long-term-care-plansHebrew Academy for Special Children, Inc. – Compliance With the Reimbursable Cost Manual
… Special Class (SC), and full- and half-day Special Class in an Integrated Setting (SCIS) programs to children with … under these programs and under the SEIT program effective in the 2015-16 fiscal year are based on fixed fees. Hebrew … year, Hebrew Academy served approximately 539 students in its SED preschool cost-based programs. The New York City …
https://www.osc.ny.gov/state-agencies/audits/2020/02/04/hebrew-academy-special-children-inc-compliance-reimbursable-cost-manualAdministration of the Contract With the Postgraduate Center for Mental Health (Follow-Up)
… of implementation of the nine recommendations included in our initial audit report, Administration of the Contract … had a severe bedbug problem. We also identified $697,938 in unsupported and/or inappropriate expenses charged to the … fees and staff travel. We also found deficiencies in efforts by OMH program staff to follow up on …
https://www.osc.ny.gov/state-agencies/audits/2020/09/15/administration-contract-postgraduate-center-mental-health-followImproper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare (Follow-Up)
… of implementation of the nine recommendations included in our initial audit report, Improper Medicaid Payments for … and supplies; and drugs. When individuals are enrolled in both Medicaid and Medicare (referred to as … services, while Medicaid is the payer of last resort. In addition to delivering services, hospice providers are …
https://www.osc.ny.gov/state-agencies/audits/2023/02/13/improper-medicaid-payments-individuals-receiving-hospice-services-covered-medicare-followMedicaid Program – Improper Fee-for-Service Pharmacy Payments for Recipients With Third-Party Health Insurance
… third-party health insurance (TPHI) for pharmacy services in addition to Medicaid (e.g., employer-based coverage, … to prevent TPHI overpayments from occurring. Beginning in 2023, pharmacy services for recipients enrolled in some managed care plans will be covered by FFS; therefore, …
https://www.osc.ny.gov/state-agencies/audits/2023/05/11/medicaid-program-improper-fee-service-pharmacy-payments-recipients-third-party-healthMedicaid Program – Improper Medicaid Payments for Outpatient Services Billed as Inpatient Claims
… inpatient and outpatient services. A recipient’s status in a hospital – inpatient versus outpatient – affects … care generally requires recipients to stay overnight in the hospital and be monitored by the health care team at … services are medical procedures that can be performed in the same day. Medicaid uses the All Patient Refined …
https://www.osc.ny.gov/state-agencies/audits/2023/08/30/medicaid-program-improper-medicaid-payments-outpatient-services-billed-inpatient-claimsChildren’s Unit for Treatment and Evaluation – Compliance With the Reimbursable Cost Manual
… documented, and allowable under the State Education Department’s (SED) guidelines, including the Reimbursable … with disabilities who are between three and five years of age. CUTE is reimbursed for these services through rates … CUTE’s tuition reimbursement rates. Remind CUTE officials of the pertinent SED requirements that relate to the …
https://www.osc.ny.gov/state-agencies/audits/2019/07/15/childrens-unit-treatment-and-evaluation-compliance-reimbursable-cost-manualMedicaid Program – Medicaid Overpayments for Medicare Part B Services Billed Directly to eMedNY
… under 65 with certain disabilities. Individuals enrolled in both programs are commonly referred to as “dual-eligible.” … deductibles and coinsurance) on behalf of dual-eligibles. In December 2009, the Department of Health (Department) … the accuracy of Medicaid payments for dual-eligibles. In certain instances, providers may still submit these claims …
https://www.osc.ny.gov/state-agencies/audits/2018/12/11/medicaid-program-medicaid-overpayments-medicare-part-b-services-billed-directly-emednyMedicaid Program – Opioid Prescriptions for Medicaid Recipients in an Opioid Treatment Program
… Medicaid recipients who are receiving opioids while also in a Treatment Program for opioid use disorder. This audit … currently faces an opioid misuse epidemic, which began in the 1990s with the over-prescribing of opioid drugs for … prescriptions. I-STOP is a tool to assist prescribers in determining the most appropriate prescription(s) for an …
https://www.osc.ny.gov/state-agencies/audits/2018/11/20/medicaid-program-opioid-prescriptions-medicaid-recipients-opioid-treatment-programMedicaid Program – Overpayments for Therapy Services and Prescription Drugs Covered by Medicare
… recipients, health care providers are required to bill Medicare, which is generally the primary payer, before … services were covered by Medicare and, therefore, did not bill Medicare. $1.5 million was paid for prescription drugs. … is not covered by Medicare, and their obligation to bill Medicare before Medicaid for services rendered to …
https://www.osc.ny.gov/state-agencies/audits/2019/10/30/medicaid-program-overpayments-therapy-services-and-prescription-drugs-covered-medicare