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Medicaid Program – Managed Care Premium Payments for Recipients With Comprehensive Third-Party Insurance
… Health (Department) made Medicaid mainstream managed care premium payments on behalf of individuals who had … Medicaid pays managed care organizations (MCOs) a monthly premium for each enrolled Medicaid recipient, and the MCOs … paid about $1.28 billion in Medicaid managed care premium payments on behalf of enrollees who also had …
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
… To determine whether UnitedHealthcare overpaid for out-of-network anesthesia services provided at Ambulatory Surgery … Program (NYSHIP), administered by the State Department of Civil Service (Civil Service), provides health insurance … The Empire Plan provides its members with four types of health insurance coverage: medical/surgical, hospital, …
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
… services to children with disabilities between the ages of three and five years. During the 2013-14 school year, … by SED. Counties are reimbursed by SED for a portion of their payments to Brookville. For the three fiscal years … to help ensure their compliance with the provisions of the Manual. To Brookville: Ensure that all costs reported …
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
… to children with disabilities who are between the ages of three and five years. During the 2014-15 school year, … served about 52 students. The New York City Department of Education (DoE) refers students to Lifeline and pays for … by SED. The DoE is reimbursed by SED for a portion of its payments to Lifeline. For the three fiscal years ended …
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
… Orthopedic Associates of Long Island, LLP 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-orthopedic-associates-long-islandMedicaid Program – Improper Payments for Controlled Substances That Exceed Allowed Dispensing Limits
… pharmacies can dispense when prescriptions are ordered via telephone or fax, due to the inherent risk of drugs ordered … allowed by the Act. In one instance, a pharmacy filled two telephone orders for alprazolam (a drug used to treat … Each order was filled for a 30-day supply even though telephone orders for this drug are limited to a five-day …
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
… the $1,480 due from the member. Eastern Orange wrote off all charges in excess of United’s payment from the member’s …
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)
… Background Our initial audit report, which was issued on August 13, 2013, determined that, for the period January 1, …
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)
… recommendations included in our initial audit report, Educators for Children, Youth and Families, Inc. - Use of … which was issued on August 20, 2010, examined whether Educators for Children, Youth and Families, Inc. (Educators) … Department/Office of Children and Family Services: Educators for Children, Youth and Families, Inc. - Use of …
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 … refer to health care services provided in the home, medical offices, clinics, and other freestanding sites. They … Department's Medicaid reimbursement policies. Some edits check various Department files to verify recipient …
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
… with applicable Medicaid laws and regulations as well as the rules and policies set forth by the Department of … of Medicaid’s payments to Joia were for patients who lived approximately one hour away (one way); and 134 of the …
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
… the facility deficiencies we identified through our site visits, OTDA officials detailed organizational, legal, …
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
… and qualified for Medicare based on his parent’s work credits. Had the child been enrolled in Medicare, the … based on their or a qualifying family member’s work credits, we identified 4,381 ESRD Medicaid recipients who did … [spouse, parent] and obtaining recipients’ qualifying work credits [“quarters of coverage,” or QCs] from SSA); and …
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
… services to children with disabilities between the ages of 3 and 4 years. For the purposes of this report, the program we reviewed is referred to as the … information reported on CFRs. St. Mary’s is a subsidiary of St. Mary’s Healthcare System for Children, Inc., a …
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)
… of implementation of the three recommendations included in our initial audit report, Improper Fee-for-Service … who are chronically ill or disabled and who wish to stay in their homes and communities. MLTC plans offer a range of … that plans must cover and pay for (benefit packages) in exchange for monthly premium payments for each member …
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
… program, and sufficiently documented pursuant to the State Education Department’s (SED) Reimbursable Cost Manual … year ended June 30, 2015, QSAC received $3.7 million in State funding for the cost-based SC and SEIT programs. The …
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
… made improper fee-for-service (FFS) payments for certain services covered by managed long-term care (MLTC) plans. The audit covered the period January 1, … enrolled in MLTC plans. MLTC plans provide long-term care services, such as home health care, nursing home care, and …
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
… operated several other programs, including SED-approved school-age programs, an Early Intervention program … a camp, and a day care program. During the 2016-17 school year, Hebrew Academy served approximately 539 students …
https://www.osc.ny.gov/state-agencies/audits/2020/02/04/hebrew-academy-special-children-inc-compliance-reimbursable-cost-manual