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United HealthCare – Overpayments for Services Provided by Eastern Orange Ambulatory Surgery Center
To determine whether Eastern Orange Ambulatory Surgery Center LLC waived Empire Plan members outofpocket costs and if so to quantify the overpayments made
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)
… with the Nassau County District Attorney and the New York State Department of Financial Services. On December 10, 2015, … February 9, 2016, and made restitution of $231,919 to the State, of which $94,460 was paid to the Medicaid for the … William Davis made full restitution of $231,919 to the State, of which $94,460 was paid to Medicaid for 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 … Medicaid provides a wide range of medical services to those who are economically disadvantaged and/or have … providers directly for Medicaid-eligible services rendered to Medicaid recipients. Under the managed care plan method, …
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)
… the 3 recs included in our initial audit report Educators for Children Youth Families Inc Use of Contract Funds …
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
… of Health's eMedNY system processes Medicaid claims for ancillary services in accordance with Medicaid … categories: diagnostic, therapeutic, and custodial. For example, laboratory, physical therapy, and home health … care are typical ancillary services. Medicaid claims for ancillary services are processed by eMedNY, the …
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
… set forth by the Department of Health (Department) and the State Education Department. Our audit covered the period … The Department is responsible for administering New York State’s Medicaid program. Medicaid is a federal, state, and locally funded program that provides a wide range …
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 … To determine if the Office of Temporary and Disability Assistance and the Department of Health are …
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
… Purpose To determine whether the Department of Health took sufficient steps to control the Medicaid costs of recipients diagnosed with … To determine whether the Department of Health took sufficient …
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
… reported on CFRs. St. Mary’s is a subsidiary of St. Mary’s Healthcare System for Children, Inc., a not-for-profit …
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 … program offers managed long-term care (MLTC) coverage to people who are chronically ill or disabled and who wish to stay in their homes and communities. MLTC plans offer a … To determine the extent of implementation of the three …
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
… costs included $111,791 in personal service costs for 107 direct care employees and 34 administration employees, and … the time of the Director of Clinical Services, $5,054 for direct hours not documented, $3,232 for a direct maintenance … appropriate adjustments to QSAC’s CFR and reimbursement rates, as warranted. Work with QSAC officials to help ensure …
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) … care, nursing home care, and durable medical equipment, to people who are chronically ill or disabled. Medicaid pays … Enrollment information is ultimately communicated to eMedNY, the Medicaid claims processing and payment system. …
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
… Class (SC), and full- and half-day Special Class in an Integrated Setting (SCIS) programs to children with … cost-based programs; $488,450 in other than personal service related party costs incorrectly charged to the SED … compensation; $76,793 in unsupported other than personal service costs; and $34,111 in unsupported personal service …
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 … sampled clients were program-eligible and were referred to the program via the proper authorities and that client … contained required documentation. However, our visits to certain client apartments identified what appeared to be …
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)
… by Medicare (Report 2018-S-71 ). About the Program Hospice is a coordinated program of home and/or inpatient care that … and Medicare (referred to as dual-eligibles), Medicare is the primary payer for Medicare-covered hospice services, while Medicaid is the payer of last resort. In addition to delivering …
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 who had third-party … To determine if Medicaid made inappropriate feeforservice payments to pharmacies on behalf of recipients who had thirdparty …
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
… recipients according to their diagnosis and severity of illness, which provides the basis for calculating the …
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
… by Children’s Unit for Treatment and Evaluation (CUTE) on its Consolidated Fiscal Reports (CFR) were properly … Cost Manual (RCM). The audit covered expenses reported on CUTE’s CFR for the fiscal year ended June 30, 2016 and certain costs reported on its CFRs for the two fiscal years ended June 30, 2015. …
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
… all costs of Part B services until their annual deductible is met. After the deductible is met, Medicare begins to pay its share and the enrollee is responsible for any coinsurance. Typically, Medicare will …
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
… recipients who are receiving opioids while also in a Treatment Program for opioid use disorder. This audit covered the period … of opioid drugs for pain-related conditions. Opioid treatment programs (Treatment Programs) provide … recipients who are receiving opioids while also in a Treatment Program for …
https://www.osc.ny.gov/state-agencies/audits/2018/11/20/medicaid-program-opioid-prescriptions-medicaid-recipients-opioid-treatment-program