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Medicaid Program – Medicaid Payments for Early Refills of Prescription Drugs and Supplies
… refills are refills on prescriptions before the previous supply has been fully used. States set early refill … dispensed amount has been used, or up to a 10-day supply of medication is remaining of the cumulative amount … policy, nearly 43% of our findings had 20 or more excess supply days. For example, we identified one member who …
https://www.osc.ny.gov/state-agencies/audits/2026/03/20/medicaid-program-medicaid-payments-early-refills-prescription-drugs-and-suppliesUnitedHealthcare – Improper Payments for Medical Services Designated By Modifier Code 59 (Follow-Up)
… Purpose To determine the implementation status of the three … Program (NYSHIP) provides health insurance coverage to active and retired State, participating local government, … (Department) contracts with UnitedHealthcare (United) to process and pay medical and surgical claims for services …
https://www.osc.ny.gov/state-agencies/audits/2017/12/27/unitedhealthcare-improper-payments-medical-services-designated-modifier-code-59-followMedicaid Program – Managed Care Premium Payments for Recipients With Comprehensive Third-Party Insurance
… Purpose To determine whether the Department of Health (Department) made Medicaid mainstream managed care … on behalf of individuals who had comprehensive third-party health insurance coverage. The audit covered the period … and locally funded program that provides a wide range of health care services to those who are economically …
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
… Purpose To determine whether UnitedHealthcare overpaid for … Surgery Centers that were contractually required to use in-network anesthesia providers. The audit covered the … To determine whether UnitedHealthcare overpaid for …
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
… provider located in Nassau County, New York. SLCD provides preschool special education services to children with … three and five years of age. SLCD is reimbursed for preschool special education services through rates set by … to direct care preschool employees; $7,152 in costs for a teacher assistant that was incorrectly charged to the …
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
… Compliance With the Reimbursable Cost Manual ( 2015-S-19 ) New York League for Early Learning, Inc.: Compliance With the …
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 determine whether the costs reported by Lifeline Center for Child Development, Inc. (Lifeline) on its Consolidated … focused primarily on expenses claimed on Lifeline’s CFR for the fiscal year ended June 30, 2015, and included certain expenses claimed on Lifeline’s CFRs for the two fiscal years ended June 30, 2014. Background …
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
… Purpose To determine whether Orthopedic Associates of Long Island, LLP waived Empire Plan members’ out-of-pocket costs, and if so, to quantify the overpayments made by United HealthCare resulting from … on claims submitted to United by Orthopedic Associates of Long Island, LLP (Orthopedic Associates), a …
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
… being diverted for inappropriate or unauthorized use. The supply limits that the Act imposes vary depending on the … that are highly prone to abuse are limited to a five-day supply, and others that carry less risk are limited to a 30-day supply. During the audit period, the Medicaid program paid …
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
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-manual