Objective

To determine whether the Department of Health’s eMedNY system reasonably ensured that Medicaid claims were submitted by approved providers, were processed in accordance with Medicaid requirements, and resulted in correct payments to providers. The audit covered the period from April 2024 through September 2024, and certain claims going back to January 2022.

About the Program

The Department of Health (DOH) administers the State’s Medicaid program. DOH’s eMedNY computer system processes claims submitted by providers for services rendered to Medicaid-eligible members and generates payments to reimburse the providers for their claims. During the 6-month period ended September 30, 2024, eMedNY processed almost 249 million claims, resulting in payments to providers of nearly $50.6 billion. The claims are processed and paid in weekly cycles, which averaged about 9.6 million claims and $1.9 billion in payments to providers.

Key Findings

The audit determined eMedNY reasonably ensured Medicaid claims were submitted by approved providers, were processed in accordance with requirements, and resulted in correct payments to providers. However, we also identified the need for improvement in the processing of certain types of claims. The audit identified over $11.5 million in improper Medicaid payments, as follows:

• $8.3 million was paid for managed care premiums on behalf of Medicaid members who should not have had managed care coverage because they had other concurrent comprehensive third-party health insurance.
• $1.6 million was paid for fee-for-service inpatient claims that should have been paid by managed care.
• $1.3 million was paid for managed care newborn birth and maternity claims that contained inaccurate information, such as low newborn birth weight, which caused increased payments.
• $222,220 was paid for inpatient, clinic, and referred ambulatory claims that did not comply with Medicaid policies.
• $53,906 was paid for claims where Medicaid was incorrectly designated as the primary payer instead of another insurer.

As a result of the audit, more than $2.6 million of the improper payments was recovered. We also identified 14 Medicaid providers who were charged with or found guilty of crimes that violated laws or regulations governing certain health care programs. In response to these findings, DOH removed 13 of the providers from the Medicaid program and referred one to the Office of the New York State Attorney General.

Key Recommendations

We made seven recommendations to DOH to recover the remaining inappropriate Medicaid payments and improve controls.