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Medicaid Program – Managed Care Organizations’ Readiness for the Encounter Intake System
… Purpose To determine the readiness of all Medicaid managed care organizations (MCOs) to submit Medicaid encounter … quality assurance, various research and analytics, managed care rate setting, and drug rebate collections. On September … have fewer enrollees than mainstream Medicaid managed care plans. According to DOH officials, the specialized plans …
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)
… our initial audit report, Monitoring of Medicaid Payments for Nursing Home Bed Reserve Days (Report 2010-S-21). … examined whether nursing home claims submitted to Medicaid for hospital bed reserve days were appropriate, and if not, … 31, 2010, our audit determined Medicaid paid $28 million for bed reserve claims that exceeded the bed reserve day …
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)
… of implementation of the three recommendations included in our initial audit report, Excessive Medicaid Payments for … ended June 30, 2009, we identified about $600 million in Medicaid payments that could have been avoided had the … pace with other states’ efforts to limit Medicaid payments in areas where Medicaid and Medicare programs overlap. The …
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
… The Empire Plan is the primary health benefits plan for NYSHIP, covering a range of services from inpatient … process and pay medical claims from health care providers for services provided to Empire Plan members. United … pay a nominal co-payment to the participating provider for the services rendered. Members may also choose to receive …
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
… (CFR) were properly calculated, adequately documented and allowable under the State Education Department’s (SED’s) … CFR, of which $3.3 million was for the Preschool Special Class and the Preschool Integrated Special Class (Programs) we audited. Key Findings We identified …
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)
… made in our audit report, Improper Payments for Controlled Substances That Exceed Allowed Dispensing … which was issued on February 6, 2015, determined that, for the period January 1, 2009 through December 31, 2013, Medicaid overpaid pharmacies $1,183,601 for 13,705 fee-for-service claims in which quantities of …
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)
… audit report, Improper Fee-for-Service Payments for Pharmacy Services Covered by Managed Care (Report 2014-S-5 ). … Medicaid inappropriately paid 29,289 fee-for-services pharmacy claims totaling $978,251 on behalf of 18,010 Medicaid recipients whose pharmacy benefits were covered by managed care. We …
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
… whether the costs reported by Starting Point Services for Children (Starting Point) on its Consolidated Fiscal … included all expenses claimed on Starting Point’s CFR for the fiscal year ended June 30, 2013, and certain expenses claimed on Starting Point’s CFRs for the two fiscal years ended June 30, 2012. Background …
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
… Background The New York State Health Insurance Program (NYSHIP) provides health insurance coverage to more than 1.2 … The Empire Plan is the primary health benefits plan for NYSHIP. The State Department of Civil Service administers the NYSHIP program and contracts with UnitedHealthcare (United) …
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
… whether the costs reported by the Milestone School for Child Development (Milestone) on its Consolidated Fiscal … The audit included all expenses claimed on Milestone’s CFR for the fiscal year 2012-13, and certain expenses claimed on Milestone’s CFRs for the two fiscal years ended June 30, 2012. Background The …
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
… range of health and social services, including supportive housing. Supportive housing is designed to help individuals and families use housing as a platform for health and recovery following a …
https://www.osc.ny.gov/state-agencies/audits/2016/02/16/administration-contract-center-urban-community-servicesMedicaid Program – Overpayments of Hospitals' Claims for Lengthy Acute Care Admissions
… Purpose To determine whether Medicaid overpaid hospitals by reimbursing for higher levels of medical care than those actually provided to patients. The audit covers the period April 1, 2005 … To determine whether Medicaid overpaid hospitals by reimbursing for higher levels of medical care than those actually …
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
… To determine whether the costs reported by All Services for Kids, Inc. (All Services) on its Consolidated Fiscal … presented in its annual CFRs. According to its CFRs for the two fiscal years ended June 30, 2010, All Services … $1.3 million in reimbursable expenses. All Services' CFR for the fiscal year ended June 30, 2011 had not been prepared …
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
… if Medicaid made improper Medicare premium payments on behalf of recipients enrolled in the Medicare buy-in … should not pay premiums for Buy-in Program coverage on behalf of individuals who do not have a benefit … made $31.7 million in improper Medicare premium payments on behalf of 42,586 individuals who did not have a benefit …
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)
To assess the extent of implementation of the three recommendations included in our 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
… whether Empire BlueCross properly paid hospital claims for intraocular procedures. The audit covered the period … The Empire Plan is the primary health benefits plan for NYSHIP, covering nearly 1.1 million members. Empire … portion of the Empire Plan. Empire processes claims for hospital services according to contracts it negotiates …
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)
… Objective To determine the extent of implementation of the seven recommendations made in our initial audit … benefits. Medicaid recipients may have additional sources of health care coverage (i.e., third-party health insurance, … To determine the extent of implementation of the seven recommendations made in our …
https://www.osc.ny.gov/state-agencies/audits/2020/01/17/managed-care-premium-payments-recipients-comprehensive-third-party-insurance-followOpioid Prescriptions for Medicaid Recipients in an Opioid Treatment Program (Follow-Up)
… included in our initial audit report, Opioid Prescriptions for Medicaid Recipients in an Opioid Treatment Program … opioid medications and counseling and behavioral therapies for people diagnosed with an opioid use disorder. The State … prescription drug use, known as the Internet System for Tracking Over-Prescribing (I-STOP), which contains …
https://www.osc.ny.gov/state-agencies/audits/2020/05/07/opioid-prescriptions-medicaid-recipients-opioid-treatment-program-followMedicaid Overpayments for Medicare Part B Services Billed Directly to eMedNY (Follow-Up)
… in our initial audit report, Medicaid Overpayments for Medicare Part B Services Billed Directly to eMedNY … B (Part B), which provides supplemental insurance coverage for outpatient medical services, physician services, and … B cost-sharing amounts (e.g., deductibles and coinsurance) for these dual-eligible individuals. Our initial audit …
https://www.osc.ny.gov/state-agencies/audits/2020/07/01/medicaid-overpayments-medicare-part-b-services-billed-directly-emedny-followMedicaid Program – Improper Payments for Drugs Without a Federal Drug Rebate Agreement
… To determine whether Medicaid inappropriately paid for drugs from manufacturers that did not enter into a national … helps to offset the costs of most covered outpatient drugs dispensed to Medicaid patients. The MDRP requires drug … for state Medicaid coverage of most of the manufacturer’s drugs. Manufacturers then pay states rebates on those drugs …
https://www.osc.ny.gov/state-agencies/audits/2024/02/23/medicaid-program-improper-payments-drugs-without-federal-drug-rebate-agreement