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Medicaid Program – Improper Payments for Controlled Substances That Exceed Allowed Dispensing Limits
… Purpose To determine whether the Department of Health paid pharmacy providers for controlled substances in compliance with the New York … supply. During the audit period, the Medicaid program paid pharmacy providers through the fee-for-service method and the … To determine whether the Department of Health paid pharmacy providers for controlled substances in compliance …
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
… Purpose To determine whether Eastern Orange Ambulatory Surgery Center, LLC waived Empire Plan members’ out-of-pocket … on claims submitted to United by Eastern Orange Ambulatory Surgery Center, LLC (Eastern Orange), a non-participating … Overpayments for Services at the Capital Region Ambulatory Surgery Center (2007-S-72) New York State Health Insurance …
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
… Purpose To determine whether Medicaid made improper fee-for-service claim payments for … October 1, 2011 through December 31, 2013. Background Medicaid provides a wide range of medical services to those … and/or have special health care needs. In general, the Medicaid program pays medical providers through either the …
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)
… submitted periodic expenditure reports to SED and OCFS. We reviewed claims amounting to $1.8 million, out of $3.2 million in contract payments, to determine if the claims were properly supported and appropriate. These … four administered by SED and three administered by OCFS. We found that Educators could not support or justify $883,530 …
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
… for review. Medicaid reimbursement rates for inpatient hospital claims include the costs of most medical care provided during a hospital admission. As such, claims for ancillary services provided during a hospital admission are generally not reimbursable. In 2007, …
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
… To determine whether Medicaid made proper payments to Joia Pharmacy, Inc. (Joia) and a related prescriber (herein … During the audit period, Joia, doing business as Soho Pharmacy, was a privately owned pharmacy located in Lower Manhattan. Soho Pharmacy was still …
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 … 16, 2016. Background According to a 2016 Department of Housing and Urban Development report, of the more than …
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
… Department of Health took sufficient steps to control the Medicaid costs of recipients diagnosed with end stage renal … alive. For the six-year period ended December 31, 2015, Medicaid paid $909 million for medical services (including … equipment, and laboratory services) on behalf of 10,906 Medicaid recipients who were diagnosed with ESRD. Medicaid …
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 Marys Hospital for Children Inc on its Consolidated Fiscal …
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 …
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
… a total of $16,503 in OTPS costs consisting of: $11,607 in rent, which consisted of $8,582 in direct rent and $3,025 in administration rent because QSAC did not claim the actual rent only; …
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
… payments for certain services covered by managed long-term care (MLTC) plans. The audit covered the period January 1, … are enrolled in MLTC plans. MLTC plans provide long-term care services, such as home health care, nursing home care, and durable medical equipment, to …
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
… preschool Special Education Itinerant Teacher (SEIT), full- and half-day Special Class (SC), and full- and half-day Special Class in an Integrated Setting …
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)
… Objective To determine the extent of implementation of the nine recommendations included in our initial audit … of the Contract With the Postgraduate Center for Mental Health ( 2015-S-88 ). About the Program Our initial report, … To determine the extent of implementation of the nine recommendations …
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)
… covered by Medicare. The audit covered the period January 1, 2015 through July 31, 2019. We determined the Department …
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
… Objective To determine if Medicaid made inappropriate fee-for-service payments to pharmacies on behalf of recipients … have other third-party health insurance (TPHI) for pharmacy services in addition to Medicaid (e.g., … made for services that should have been paid for by a recipient’s TPHI. During the audit period, Gainwell’s …
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
… in the same day. Medicaid uses the All Patient Refined Diagnosis Related Groups (DRG) methodology to reimburse … DRG methodology classifies recipients according to their diagnosis and severity of illness, which provides the basis …
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
… To determine whether the costs reported by Childrens Unit for Treatment and Evaluation on its …
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
… After the deductible is met, Medicare begins to pay its share and the enrollee is responsible for any coinsurance. … to minimize the need for providers to self-report Medicare claim data to eMedNY and thereby improve the accuracy of … appropriate. Formally advise providers to report accurate claim information when billing Medicaid for Part B …
https://www.osc.ny.gov/state-agencies/audits/2018/12/11/medicaid-program-medicaid-overpayments-medicare-part-b-services-billed-directly-emedny