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United 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-island

Medicaid 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-limits

United 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-center

Payments 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-follow

Medicaid 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-care

Educators 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-follow

Medicaid 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-inpatient

Medicaid 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-prescriber

Oversight 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-residency

Medicaid 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-disease

St. 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-manual

Improper 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-follow

Quality 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-manual

Medicaid 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-plans

Hebrew Academy for Special Children, Inc. – Compliance With the Reimbursable Cost Manual

… to the State Education Department’s (SED) Reimbursable Cost Manual (RCM). The audit focused primarily on expenses … 30, 2015 are collectively referred to as the SED preschool cost-based programs. Hebrew Academy also operated three other … served approximately 539 students in its SED preschool cost-based programs. The New York City Department of …

https://www.osc.ny.gov/state-agencies/audits/2020/02/04/hebrew-academy-special-children-inc-compliance-reimbursable-cost-manual

Administration of the Contract With the Postgraduate Center for Mental Health (Follow-Up)

… With the Postgraduate Center for Mental Health ( 2015-S-88 ). About the Program Our initial report, issued December …

https://www.osc.ny.gov/state-agencies/audits/2020/09/15/administration-contract-postgraduate-center-mental-health-follow

Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare (Follow-Up)

… Hospice is a coordinated program of home and/or inpatient care that treats terminally ill individuals and their … Hospice programs provide palliative care, including nursing, physician, and counseling services; home health … providers are responsible for developing a comprehensive plan of care and coordinating care and services needed by …

https://www.osc.ny.gov/state-agencies/audits/2023/02/13/improper-medicaid-payments-individuals-receiving-hospice-services-covered-medicare-follow

Medicaid 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-health