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United HealthCare – Overpayments for Services Provided by Eastern Orange Ambulatory Surgery Center
… Purpose To determine whether Eastern Orange Ambulatory Surgery Center, LLC waived Empire Plan members’ out-of-pocket costs, and if so, to quantify the overpayments made by United HealthCare resulting from … on claims submitted to United by Eastern Orange Ambulatory Surgery Center, LLC (Eastern Orange), a non-participating …
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)
… and Improper Claims Submitted by Davis Ethical Pharmacy (2012-S-11). Background Our initial audit report, which was issued on August 13, 2013, determined that, for the period January 1, 2008 through December 13, 2011, Medicaid made improper payments totaling $94,460 to …
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
… Purpose To determine whether Medicaid made improper fee-for-service claim payments for pharmacy services covered by recipients’ managed care … program pays medical providers through either the fee-for-service method or the managed care plan method. Under the … Medicaid made improper feeforservice claim payments for pharmacy services covered by recipients managed care plans …
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)
… in our initial audit report, Educators for Children, Youth and Families, Inc. - Use of Contract Funds (Report … August 20, 2010, examined whether Educators for Children, Youth and Families, Inc. (Educators) appropriately used State … of Children and Family Services: Educators for Children, Youth and Families, Inc. - Use of Contract Funds (2007-S-128) …
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
… Purpose To determine whether the Department of Health's eMedNY system processes Medicaid claims for ancillary services in accordance with Medicaid … To determine whether the Department of Healths eMedNY system processes Medicaid claims for …
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
… (Joia) and a related prescriber (herein referred to as “the Doctor”) in compliance with applicable Medicaid laws and … still in business at the time of this report; however, it has operated under different corporate ownership since 2014. … wherein the drug and drug strength were different from what the physician prescribed; and Claims for unauthorized …
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
… Purpose To determine if the Office of Temporary and Disability Assistance (OTDA) and the Department of Health (DOH) are adequately ensuring that hotels and motels used for … To determine if the Office of Temporary and Disability Assistance and the Department of …
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
… diagnosed with end stage renal disease who were eligible for, but not enrolled in, Medicare. The audit covered the … amount of time under Social Security, the Railroad Retirement Board, or as a government employee; (2) are … Medicare, or take actions to help (or encourage) them to apply and enroll in Medicare. As a result, we identified …
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 … (CFRs) were reasonable, necessary, directly related to the special education program, and sufficiently documented … To determine whether the costs reported by St Marys Hospital for Children Inc on …
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)
… Objective To determine the extent of implementation of the three recommendations included in our initial audit … To determine the extent of implementation of the three recommendations included in …
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
… Objective To determine whether the costs reported by Quality Services for the Autism Community (QSAC) on its Consolidated Fiscal Report … (CFR) were reasonable, necessary, directly related to the special education program, and sufficiently documented … To determine whether the costs reported by Quality Services for the Autism …
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
… Objective The objective of this audit was to determine whether the Department of Health (Department) made improper fee-for-service (FFS) payments for certain services covered by … The objective of this audit was to determine whether the Department of …
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
… To determine whether the costs reported by the Hebrew Academy for Special Children, Inc. (Hebrew Academy) on its Consolidated Fiscal Reports (CFRs) were … The audit focused primarily on expenses claimed on Hebrew Academy’s CFR for the fiscal year ended June 30, 2017 and …
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)
… documentation. However, our visits to certain client apartments identified what appeared to be ongoing conditions … the health and/or safety of clients. For example, three apartments had significantly damaged ceilings/walls, two did …
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)
… Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare (Report 2018-S-71 ). About the … care, including nursing, physician, and counseling services; home health aides; physical and occupational … Medicare is the primary payer for Medicare-covered hospice services, while Medicaid is the payer of last resort. In …
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
… have other third-party health insurance (TPHI) for pharmacy services in addition to Medicaid (e.g., … is considered the payer of last resort and, as such, FFS pharmacy providers are required to coordinate benefits with … period, Gainwell’s third-party liability recoveries on FFS pharmacy payments totaled almost $53 million. Key Findings We …
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
… services that were erroneously billed as inpatient claims. The audit covered the period from January 2018 … The audit identified 34,264 fee-for-service inpatient claims, totaling $360.6 million, where hospitals reported … of admission. There is a high risk that a portion of these claims were improper if the services provided should have …
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
… of age. CUTE is reimbursed for these services through rates set by SED. The reimbursement rates are based on financial information, including costs, … on CUTE’s CFRs and to CUTE’s tuition reimbursement rates. Remind CUTE officials of the pertinent SED …
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
… whether Medicaid made improper payments to providers who submitted Part B cost-sharing claims directly to eMedNY. The … whether Medicaid made improper payments to providers who submitted Part B costsharing claims directly to eMedNY …
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
… Purpose To determine if the Department of Health has taken sufficient steps to … are receiving opioids while also in a Treatment Program for opioid use disorder. This audit covered the period October 1, 2013 through September 30, 2017. … To determine if the Department of Health has taken sufficient steps to …
https://www.osc.ny.gov/state-agencies/audits/2018/11/20/medicaid-program-opioid-prescriptions-medicaid-recipients-opioid-treatment-program