Medicaid Program – Improper Medicaid Payments for Claims Not in Compliance With Ordering, Prescribing, Referring, and Attending Requirements

Issued Date
August 17, 2021
Health, Department of (Medicaid Program)


To determine whether the Department of Health (Department) paid for claims in violation of federal and State regulations that require an appropriate National Provider Identifier (NPI) for ordering, prescribing, referring, and attending (OPRA) health care providers. The audit covered the period from January 1, 2014 through December 31, 2018.

About the Program

The New York State Medicaid program provides a wide range of medical services to those who are economically disadvantaged and/or have special health care needs. For the State fiscal year ended March 31, 2020, New York’s Medicaid program had approximately 7.3 million recipients and Medicaid claim costs totaled $69.8 billion (comprising $27.4 billion in fee-for-service health care payments and $42.4 billion in managed care premium payments).

The Affordable Care Act and implementing federal regulations mandated that state Medicaid agencies require all ordering and referring physicians and other professionals providing services through the Medicaid fee-for-service program to be enrolled as participating providers and their NPIs to be included on Medicaid claims. Accordingly, beginning January 1, 2014, New York’s Medicaid program required that physicians and other health care professionals who order, prescribe, refer, or attend Medicaid services be appropriately screened and enrolled in Medicaid.

Through the screening and provider enrollment process, the Department gains a level of assurance over the OPRA provider’s validity to provide Medicaid services. It further allows the Department to verify the provider’s licensing and other credentials to furnish services. Additionally, the Department must verify that all providers are not prohibited from participating in a Medicaid program by the federal government, which further enhances the safety of the Medicaid program and its members.

Key Findings

The audit identified system processing weaknesses in eMedNY, the Medicaid claims processing and payment system, which improperly allowed payments for Medicaid claims that did not contain an appropriate NPI in the OPRA fields and resulted in:

  • $1.5 billion in payments for clinic and professional claims that did not contain an appropriate referring or attending NPI (for example, some claims contained NPIs of providers who were not enrolled in Medicaid while other claims did not contain an NPI);
  • $57.3 million in payments for pharmacy claims that did not contain an appropriate prescriber NPI (for example, claims contained NPIs of prescribers who were not enrolled in Medicaid, including NPIs of prescribers not known by the Department’s systems to be properly licensed); and
  • $19.4 million in payments for claims that contained an OPRA NPI but, according to regulations, should not be included on Medicaid claims or that should be further reviewed by the Department due to past misconduct.

Key Recommendations

  • Review the Medicaid payments for claims not containing an appropriate OPRA NPI identified by the audit and determine an appropriate course of action.
  • Enhance system controls to prevent improper Medicaid payments for claims not containing an appropriate OPRA NPI.

Andrea Inman

State Government Accountability Contact Information:
Audit Director: Andrea Inman
Phone: (518) 474-3271; Email: [email protected]
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236