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United HealthCare – Overpayments for Services Provided by Long Island Laparoscopic Surgery
… will result in United making an excessive payment on the claim. Our audit focused on claims submitted to United by … the period July 1, 2011 through March 31, 2015. On one claim, for example, Long Island Laparoscopic charged $27,000 … for the service. As a result, United paid $10,800 on the claim and the member’s out-of-pocket portion of the claim …
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
… allowable under the State Education Department’s (SED’s) guidelines, including the Reimbursable Cost Manual (RCM). The … for reimbursement, reported costs must comply with the guidelines specified in the RCM. For the fiscal year ended … rates. Remind Astor officials of the pertinent SED guidelines that relate to the deficiencies we identified To …
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)
… audit report, Improper Payments for Controlled Substances That Exceed Allowed Dispensing Limits (Report 2013-S-59). … The Act limits the quantities of controlled substances that pharmacies can dispense when prescriptions are ordered … report, which was issued on February 6, 2015, determined that, for the period January 1, 2009 through December 31, …
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)
… Improper Fee-for-Service Payments for Pharmacy Services Covered by Managed Care (Report 2014-S-5 ). Background Our initial audit report, which was issued … for Pharmacy Services Covered by Managed Care (2014-S-5) …
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
… remove a tumor and to repair blood vessels and a sciatic nerve that resulted from the removal of the tumor. However, … the three procedures - the repair of the blood vessels and nerve - because they were not distinct or independent of the … have paid, $6,250 for the repair of the blood vessels and nerve. Using statistically valid methods, we estimate, with a …
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 … ended June 30, 2012. Background The Milestone School for Child Development provides full-day preschool special … whether the costs reported by Milestone School for Child Development on its CFRs were properly documented …
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
… Purpose We audited the New York City Department of Health and Mental Hygiene’s … (DOHMH) administration of a contract (#113 225 01) with the Center for Urban Community Services (CUCS) for the period July 1, 2010 through July 15, 2015. The audit … We audited the New York City Department of Health and Mental Hygienes …
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
… Purpose To determine whether the Department of Health established adequate controls over inpatient claims … 1, 2009 through June 30, 2014. Background The Department of Health (Department) administers the State’s Medicaid … Other Related Audits/Reports of Interest Department of Health: Improper Medicaid Payments for Misclassified …
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
… Purpose To determine whether Medicaid overpaid hospitals by reimbursing for higher levels of medical care … care. When billing Medicaid for inpatient services, hospitals must indicate a patient's level of care on a claim … less costly) Alternate Level of Care (ALC) setting, hospitals should not bill Medicaid for more intensive acute …
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
… Purpose To determine whether the costs reported by All Services for Kids, Inc. (All Services) on its … Services tuition and fees according to rates established by SED. These rates were based on the financial information … allocated rental expenses, cell phones used by the Executive Director's minor children, unaccounted-for …
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
… to ensure accurate eligibility determinations and timely closure of Buy-in Program cases for ineligible individuals. …
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 ). … occupational, and speech therapy services as well as prescription drugs. When these services are rendered to … care providers’ Medicaid claims for therapy services and prescription drugs that are covered by Medicare. The audit …
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
… To determine whether Empire BlueCross properly paid hospital claims for intraocular procedures. The audit covered … million members. Empire BlueCross (Empire) administers the hospital portion of the Empire Plan. Empire processes claims for hospital services according to contracts it negotiates with …
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)
… medical services that range from hospital care and physician services to dental and pharmacy benefits. Medicaid … to recover premiums from all MCOs regardless of an MCO’s relationship with a recipient’s third-party insurer. In … recovery of premiums from all MCOs regardless of the MCO’s relationship with the third-party insurer. Of the initial …
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)
… therapies for people diagnosed with an opioid use disorder. The State maintains a database to monitor … opioids while also in a Treatment Program for opioid use disorder. The audit covered the period October 1, 2013 … opioids as part of a Treatment Program for opioid use disorder. These recipients may have received inappropriate, …
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)
… Objective To determine the extent of implementation of the five … Overpayments for Medicare Part B Services Billed Directly to eMedNY (Report 2017-S-36 ). About the Program The … To determine the extent of implementation of the five …
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
… from manufacturers that did not enter into a national drug rebate agreement (NDRA). The audit covered the period … administers New York’s Medicaid program. The Medicaid Drug Rebate Program (MDRP) helps to offset the costs of most … drugs dispensed to Medicaid patients. The MDRP requires drug manufacturers to enter into an NDRA with the Department …
https://www.osc.ny.gov/state-agencies/audits/2024/02/23/medicaid-program-improper-payments-drugs-without-federal-drug-rebate-agreementCompliance With Special Education Regulations for the Provision of Services (Follow-Up)
… education. The New York City Department of Education (DOE) – the nation’s largest school system – served … 192,000 of these students in the 2021-22 school year. The DOE is responsible for evaluating students to determine their … receive appropriate services. Toward this end, the DOE follows a multi-step evaluation and placement process. …
https://www.osc.ny.gov/state-agencies/audits/2023/03/15/compliance-special-education-regulations-provision-services-followMedicaid Program – Improper Medicaid Payments for Recipients Diagnosed With Severe Malnutrition
… the appropriate International Classification of Diseases (ICD) code on its claim to reflect the diagnosis. Generally, …
https://www.osc.ny.gov/state-agencies/audits/2019/04/08/medicaid-program-improper-medicaid-payments-recipients-diagnosed-severe-malnutrition