Improper Medicaid Payments for Claims Not in Compliance With Ordering, Prescribing, Referring, and Attending Requirements (Follow-Up)

Issued Date
September 13, 2023
Health, Department of (Medicaid Program)


To assess the extent of implementation of the 12 recommendations included in our initial audit report, Improper Medicaid Payments for Claims Not in Compliance With Ordering, Prescribing, Referring, and Attending Requirements (Report 2019-S-2).

About the Program

The Department of Health (Department) administers New York’s Medicaid program. Physicians and other health care professionals who order, prescribe, refer, or attend (OPRA) Medicaid services must be appropriately screened and enrolled in Medicaid. Through these processes, 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 provider's National Provider Identifier (NPI) must be included on Medicaid claims.

The objective of our initial audit report, issued August 17, 2021, was to determine whether the Department paid for claims in violation of federal and State regulations that require an appropriate NPI for OPRA health care providers. The audit covered the period from January 1, 2014 through December 31, 2018. 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. We determined Medicaid made over $1.5 billion in improper and questionable payments where eMedNY processed claims that did not contain an enrolled or affiliated OPRA NPI as required or where the OPRA NPI was not properly validated by the Department at the time of payment, and $19.4 million in payments for claims that contained an OPRA NPI that should not be included on Medicaid claims or that should be further reviewed by the Department due to past misconduct.

Key Findings

Department officials made limited progress in addressing the problems we identified in the initial audit report, and additional actions are still needed. For example, none of the improper and questionable payments have been reviewed, nor have system controls been enhanced to prevent payment for claims containing excluded or otherwise inappropriate OPRA providers. Furthermore, the Department has not improved controls to prevent improper use of the pharmacy override option and, as a result, we identified another $11.3 million in improper pharmacy payments since the initial audit. Of the initial report’s 12 audit recommendations, one was implemented, three were partially implemented, and eight were not implemented.

Key Recommendation

Officials are given 30 days after the issuance of this report to provide information on any actions planned to address the unresolved issues discussed in this follow-up.

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