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Medicaid Program – Medicaid Payments for Early Refills of Prescription Drugs and Supplies
… Objective To determine whether Medicaid made improper payments on pharmacy claims for early refills of prescription drugs and supplies. The audit covered the period from April … To determine whether Medicaid made improper payments on pharmacy claims for early refills of prescription drugs …
https://www.osc.ny.gov/state-agencies/audits/2026/03/20/medicaid-program-medicaid-payments-early-refills-prescription-drugs-and-suppliesUnitedHealthcare – Improper Payments for Medical Services Designated By Modifier Code 59 (Follow-Up)
… Purpose To determine the implementation status of the three recommendations made in our audit report, … By Modifier Code 59 (Report 2013-S-82 ). Background The New York State Health Insurance Program (NYSHIP) provides … To determine the implementation status of the three recommendations made …
https://www.osc.ny.gov/state-agencies/audits/2017/12/27/unitedhealthcare-improper-payments-medical-services-designated-modifier-code-59-followMedicaid Program – Managed Care Premium Payments for Recipients With Comprehensive Third-Party Insurance
… Purpose To determine whether the Department of Health (Department) made Medicaid … had comprehensive third-party health insurance coverage. The audit covered the period January 1, 2012 to September 1, 2017. Background … To determine whether the Department of Health made Medicaid mainstream managed …
https://www.osc.ny.gov/state-agencies/audits/2018/06/13/medicaid-program-managed-care-premium-payments-recipients-comprehensive-third-partyUnitedHealthcare – Overpayments for Out-of-Network Anesthesia Services Provided at In-Network Ambulatory Surgery Centers
… abuse. Civil Service contracts with UnitedHealthcare (United) to administer the medical/surgical portion of the … surgery, physical therapy, and home care services. United processes and pays claims from health care providers … may also choose to receive services from out-of-network (non-participating) providers. United’s contracts with certain …
https://www.osc.ny.gov/state-agencies/audits/2018/08/13/unitedhealthcare-overpayments-out-network-anesthesia-services-provided-network-ambulatorySchool for Language and Communication Development – Compliance With the Reimbursable Cost Manual
… School for Language and Communication Development (SLCD) on its Consolidated Fiscal Reports (CFR) were properly … Cost Manual (RCM). The audit covered the expenses reported on SLCD’s CFR for the fiscal year ended June 30, 2015, and certain expenses reported on SLCD’s CFRs for the two fiscal years ended June 30, 2014. …
https://www.osc.ny.gov/state-agencies/audits/2018/04/16/school-language-and-communication-development-compliance-reimbursable-cost-manualBrookville Center for Children’s Services, Inc. – Compliance With the Reimbursable Cost Manual
… reported by Brookville Center for Children’s Services, Inc. (Brookville) on its Consolidated Fiscal Reports (CFRs) … programs. During the same three fiscal years, NYSARC, Inc. - Nassau County Chapter (AHRC), a related party, … Manual ( 2015-S-19 ) New York League for Early Learning, Inc.: Compliance With the Reimbursable Cost Manual ( …
https://www.osc.ny.gov/state-agencies/audits/2017/10/04/brookville-center-childrens-services-inc-compliance-reimbursable-cost-manualLifeline Center for Child Development, Inc. – Compliance With the Reimbursable Cost Manual
… $31,313 in ineligible expenses, including $21,083 in taxi fares to transport parents and their children to Lifeline for … Lifeline used an allocation methodology that was neither fair nor reasonable to allocate $24,337 of its plant …
https://www.osc.ny.gov/state-agencies/audits/2017/10/12/lifeline-center-child-development-inc-compliance-reimbursable-cost-manualUnited HealthCare – Overpayments for Services Provided by Orthopedic Associates of Long Island
… Purpose To determine whether Orthopedic Associates of Long Island, LLP waived Empire Plan members’ out-of-pocket … on claims submitted to United by Orthopedic Associates of Long Island, LLP (Orthopedic Associates), a non-participating provider located in Long Island, New York. During the period January 1, 2011 …
https://www.osc.ny.gov/state-agencies/audits/2016/05/05/united-healthcare-overpayments-services-provided-orthopedic-associates-long-islandMedicaid Program – Improper Payments for Controlled Substances That Exceed Allowed Dispensing Limits
… Purpose To determine whether the Department of Health paid pharmacy … of health care services, including prescription drugs, to individuals who are economically disadvantaged and/or have … State Controlled Substances Act (Act), which was enacted to combat illegal use of controlled substances, limits the …
https://www.osc.ny.gov/state-agencies/audits/2015/02/06/medicaid-program-improper-payments-controlled-substances-exceed-allowed-dispensing-limitsUnited HealthCare – Overpayments for Services Provided by Eastern Orange Ambulatory Surgery Center
… Orange Ambulatory Surgery Center, LLC waived Empire Plan members’ out-of-pocket costs, and if so, to quantify the … school district employees and their dependents. The Empire Plan is the primary health benefits plan for NYSHIP, covering a range of services from inpatient …
https://www.osc.ny.gov/state-agencies/audits/2016/05/05/united-healthcare-overpayments-services-provided-eastern-orange-ambulatory-surgery-centerPayments for Fraudulent and Improper Claims Submitted by Davis Ethical Pharmacy (Follow-Up)
… Payments for Fraudulent and Improper Claims Submitted by Davis Ethical Pharmacy (2012-S-11). Background Our initial … 2011, Medicaid made improper payments totaling $94,460 to Davis Ethical Pharmacy. Based on information obtained from … indicated on the claims), auditors determined that Davis Ethical likely fabricated nearly all of the improper …
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
… Medicaid made improper fee-for-service claim payments for pharmacy services covered by recipients’ managed care plans. … provided to their enrollees. Prior to October 2011, pharmacy benefits were reimbursed through the fee-for-service … care coverage. However, beginning October 1, 2011, most pharmacy benefits were covered by managed care plans, and …
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)
… Purpose To determine the extent of implementation of the three recommendations included in our initial audit report, Educators for Children, Youth and Families, Inc. - Use of Contract Funds … Determine the extent of implementation of the 3 recs included in our initial audit …
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
… refer to health care services provided in the home, medical offices, clinics, and other freestanding sites. They … to verify recipient eligibility, provider credentials, and medical necessity. Other edits compare claims to each other … for inpatient hospital claims include the costs of most medical care provided during a hospital admission. As such, …
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
… Purpose To determine whether Medicaid made proper payments to Joia Pharmacy, Inc. (Joia) and a related prescriber … To determine whether Medicaid made proper payments to Joia Pharmacy Inc and a related prescriber in compliance …
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
… Department of Health (DOH) are adequately ensuring that hotels and motels used for homeless and mixed-use temporary residency are properly … New York City (NYC). Counties throughout the State utilize hotels and motels to house a substantial portion of their … and the Department of Health are adequately ensuring that hotels and motels used for …
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
… 31, 2015. Background End stage renal disease (ESRD) is a medical condition in which a person has permanent kidney … ended December 31, 2015, Medicaid paid $909 million for medical services (including inpatient, clinic, … referred ambulatory, transportation, durable medical equipment, and laboratory services) on behalf of …
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
… To determine whether the costs reported by St. Mary’s Hospital for Children, Inc. (St. Mary’s) on its Consolidated … 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)
… Covered by Managed Long-Term Care Plans (Report 2018-S-65 ). About the Program The State’s Medicaid program offers … for each member enrolled. Some services are excluded (i.e., carved out) from benefit packages and may be paid separately by Medicaid fee-for-service (FFS). The …
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
… Autism Community (QSAC) on its Consolidated Fiscal Report (CFR) were reasonable, necessary, directly related to the … the Office for People With Developmental Disabilities was $49 million, or 85 percent of QSAC’s total cost of $57.6 million. The remaining $4.9 million is the cost of other …
https://www.osc.ny.gov/state-agencies/audits/2019/12/31/quality-services-autism-community-compliance-reimbursable-cost-manual